Savannah Clinic Associates, LLC
Patient Medical History cont.:
Name:__________________________
Past medical history: (please check any that you have now or have had in the past)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
ADD/ADHD
Abnormal Pap Smears
Alcoholism
Allergies
Anemia
Anorexia
Anxiety
Arthritis
Asthma
Autoimmune Disease
Back Pain, Chronic
Bipolar Disorder
Blood Disease
Bulimia
Cancer:__________
Clotting Disorder
Colon Polyp
COPD
Coronary Artery
Disease
Depression, Current
Diabetes I
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Diabetes II
Diabetes, Gestational
Diverticular Disease
Drug Abuse
Depression, Past
Ear
Problem:_________
Eczema
Endometriosis
Erectile Dysfunction
Eye
Problem:_________
Fibromyalgia
Gall Stones
Gastritis/Gastric Ulcer
Genital Herpes
Glaucoma
Heart Attack
Heart Disease
Heart Murmur
Heartburn/Reflux
Hemorrhoids
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Hepatitis A B C
High Cholesterol
High Blood Pressure
HIV/AIDS
Irregular Heart
Rhythm
Irritable Bowel
Syndrome
Joint Problems
Kidney Disease
Kidney Stones
Liver Disease
Low Blood Pressure
Lung Disease
Memory Problems
Migraines
Multiple Sclerosis
Muscle Problems
Narcolepsy
Obesity
Osteopenia
Osteoporosis
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Pancreatitis
Parkinson’s Disease
Peripheral Vascular
Disease
Postmenopausal
Prostate Enlargement
Psychiatric Disorder
Restless Leg
Syndrome
Rheumatoid Arthritis
Scoliosis
Seizure Disorder
Skin Problem
Sleep Apnea
STD:___________
Stroke
Thyroid, Low
Thyroid, High
Tuberculosis
Vasculitis
Past Surgical History: (check all surgeries that you have had and circle corresponding side Right or Left.)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Appendix
Breast Augmentation
Breast Biopsy L R
Breast Lumpectomy L R
Breast Mastectomy L R
C-section #_______
Cataract removal L R
Coronary artery bypass: # of
vessels:___________
o
o
o
o
o
o
o
Ear tubes
Gall bladder
Hysterectomy, Total
Hysterectomy, Partial
Heart Bypass
Hernia Repair
Knee surgery:___________
Back Surgery:___________
Neck Surgery:___________
Shoulder Surgery:________
Prostate Surgery
Thyroid Surgery:_________
Tonsils
Tubal Ligation
Vasectomy
Other:_________________
Health Maintenance: (List month/year of last screening/evaluation)
Bone Density:
Mammogram:
PSA:
Last Pap:
Colonoscopy:
Eye Exam:
Family History:
_____Heart Disease
who?_______________
_____High Blood Pressure who?_______________
_____Diabetes
who?_______________
_____Stroke
who?_______________
_____Cancer
who?_______________
_____High Cholesterol
_____Depression
_____Dementia
_____Thyroid
_____Other_____________
who?________________
who?________________
who?________________
who?________________
who?________________
updated 04/24/2014