Patient History Form Name_____________________________________________________Date of Birth________________ First Middle Last Referring Physician:_________________________ Primary Care Physician: ______________________ Why are you here today? _______________________________________________________________ Have you had any x-rays, ultrasounds, or CT Scans pertinent to today’s visit? If so, did you bring a copy of the films with you today? Yes or No YES NO Where did you have the x-ray, ultrasound, CT, MRI, or other ___________________________ Allergies: List any medications that you are allergic to and the reaction you have: ________________________________ _____________________________________ ________________________________ ______________________________________ ________________________________ ______________________________________ Other Allergies: List any other allergies (bee stings, etc) ___________________________________ Medications (please list all your medications and their dosages) Medication Dosage _____________________________________________ ________________________________ _____________________________________________ ________________________________ _____________________________________________ ________________________________ _____________________________________________ ________________________________ _____________________________________________ ________________________________ _____________________________________________ ________________________________ _____________________________________________ ________________________________ _____________________________________________ ________________________________ If you need more room use back of sheet What Pharmacy do you use? ____________________________________________________________ Name and Location Do you take any blood thinners, aspirin, Motrin, anti-inflammatories, Ibuprofen, or arthritis medications? Y or N (if yes, please list) Past Medical History Have you ever had any of the following conditions? Cardiovascular Angina (chest pain) Arrhythmia (irregular heartbeat) Atrial Fibrillation Bleeding Disorder Congestive Heart Failure Coronary Artery Disease Deep Vein Thrombosis (blood clot) Heart Attack Heart Valve Problems Hypertension (High Blood Pressure) Stroke Endocrine/Metabolic Diabetes not requiring Insulin Diabetes requiring Insulin Gout Hyperthyroid (high thyroid) Hyothyroid (low thyroid) General High Cholesterol Polycystic Kidneys Sleep Apnea Gastrointestinal Crohns Disease Diverticulitis GERD / Acid Reflux Hemorrhoids Hepatic/Liver Failure/Cirrhosis Hepatitis Irritable Bowel Disease Pancreatitis Peptic Ulcer Disease Ulcerative Colitis Cancer ________________________________ ________________________________ Specify what type(s) cancer Have you received the flu vaccination this year? Genitourinary AIDS BPH (Benign Prostatic Hypertrophy) Chronic Renal Failure Elevated PSA Fertility Problems Hematuria (blood in urine) HIV Kidney Cancer Kidney Stones Prostate Cancer Recurrent Urine Infection Bladder Cancer Venereal Disease GYN/OB Breast Cancer Endometrosis Ovarian Cyst Uterine Fibroids HEENT Glaucoma Mumps Musculoskeletal Arthritis Back Pain Fibromyalgia Neuro/Psych Alcoholism Alzheimer’s Parkinson’s Seizures Spinal Cord Injury Respiratory Asthma COPD Emphysema Pulmonary Embolism Tuberculosis NO YES (when_______________________) Any other conditions not listed above _____________________________________________________ Past Surgical History: (check all the surgeries you have had and indicate the year you had the surgery) Cardiovascular Angioplasty / Stents Artificial Heart Valve Aortic Aneurysm Coronary Bypass Carotid Artery Surgery Pacemaker or Defibrillator Gynecology Cystocele Repair (dropped bladder) Hysterectomy thru Abdominal Incision Hysterectomy thru Vaginal Incision Ovary Removal (one or both) Rectocele Repair (dropped rectum) Tubal Ligation Incontinence Surgery General Brain Surgery Laminectomy (Back Surgery) HEENT Cataract Surgery Nasal Surgery Thyroid Surgery Tonsillectomy Gastrointestinal Appendectomy Bariatric (obesity) Surgery Bowel (intestine) resection Cholecystectomy (Gall Bladder Removed) Colonoscopy Inguinal Hernia Repair Ileostomy Genitourinary Nephrectomy (Kidney Removal) Left Side Right side Kidney Stone Surgery Penile Prosthesis Prostate Biopsy Prostate Radiation Radical Prostatectomy (for prostate Cancer) Testicular Surgery Enlarged Prostate Surgery Artificial Urinary Sphincter Musculoskeletal Amputation Back Surgery Cervial Spine (Neck) Surgery Hip Surgery Joint Replacement Surgery Which joint__________________ Knee Surgery Shoulder Surgery Skin Respiratory Melanoma Lung Surgery Other Skin Cancer Other Surgeries Not Listed _______________________________ _______________________________ _______________________________ _______________________________ Have you been instructed by a physician to use special antibiotics before medical procedures because you have a serious heart valve condition or rheumatic fever. If so, PLEASE list the condition: ____________________________________________________________________________________ Last Menstrual Period _______________________ What are you currently using for birth control? __________________________________________ Women Only: Number of pregnancies ______________ Number of babies delivered ___________ Family History (check if any of your relatives have had) Cancer – Other Diabetes Heart Attack High Blood Pressure Kidney Cancer Kidney Failure Kidney Stones Prostate Cancer Stroke Social History Marital Status: ____________ # of children: ___________ Do you use illicit drugs? YES NO Occupation (If retired, list prior occupation) _____________ Do you drink alcohol? YES NO Do you use tobacco? YES Have you ever smoked? NO If yes, do you drink daily? If yes how much _______________ type: _________________ # of Packs per day: ______________ YES NO If so, how many years ago did you quit? ____________ Review of Systems Do you currently have any problems related to the following? Circle Yes or No. Please explain any yes answers in the space provided. Constitutional Symptoms Fever Weight Loss Yes Yes Integumentary No No Yes Yes No No Allergic/Immunologic Hay Fever Seasonal Allergies Yes Yes No No Yes Yes No No Yes Yes No No Sore throat Sinus problems Yes Yes No No Frequent Cough Yes Shortness of Breath Yes No No Hematologic/Lymphatic Yes Yes No No Gastrointestinal Hepatitis Yes Blood Clot Problems Yes No No Psychological Bloody Stool Yes Indigestion/HeartburnYes No No Cardiovascular Chest Pain Irregular Heartbeat Gout Muscle Cramps Respiratory Endocrine Excess Thirst Too Hot or Cold No No Ear, Nose, and Throat Neurological Headache Dizzy Spells Yes Yes Musculoskeletal Eyes Blurred Vision Glaucoma Persistent Itch Rash Yes Yes No No Anxiety Depression Yes Yes No No