MEDICAL HISTORY
DATE _________________
HEIGHT____________________________ WEIGHT________________________ REFERRED BY______________________________________________________
CHIEF COMPLAINT OR REASON FOR CONSULTATION ______________________________________________________________________________________
PLEASE LIST ALL MAJOR SYMPTOMS _____________________________________________________________________________________________________
PREVIOUS SURGERIES AND APPROXIMATE YEAR __________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
WHAT DRUGS DO YOU TAKE NOW AND DOSAGE___________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
ASPIRIN:
NO
LATEX ALLERGY
YES
NO
HERBAL SUPPLEMENTS:
NO
YES
DRUG ALLERGIES_________________________________________
YES
H&N
Any eye disease, faulty sight
Easy tearing
Any ear disease,
Any trouble with nose, sinuses, mouth
throat
Hard lumps on tongue, lips, mouth
Glaucoma
Double vision
Sleep Apnea
Use CPAP
NO
NO
NO
YES
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
CVR
Chronic/frequent cough
Chest pain, angina pectoris
Spitting up of blood
Wake up short of breath
Palpitation or fluttering heart
Swelling of hands, feet, ankles
Mitral Valve Prolapse
Heart Murmur
Heart Attack
Emphysema
Asthma
High Blood Pressure
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
GI
Stomach trouble, ulcer, pain
Indigestion, vomiting, nausea
Gallbladder disease
Hemorrhoids, rectal bleeding
Any black bowel movement
Cirrhosis of liver
Gastric/Acid Reflux
Hepatitis
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
GU
Kidney disease or stone
Bladder disease
Difficulty controlling urine
Difficulty or pain on urination
Urinate more than usual
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
NO
YES
NO
YES
Tobacco use?
If yes, how much? ______________
Alcohol use?
Avg number drinks per week _________
ENDO
Thyroid disease
Diabetes
Do you take insulin
NO
NO
NO
YES
YES
YES
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
NO
YES
NO
YES
NO
YES
NEURO
Fainting spells
Loss of consciousness
Convulsions/epilepsy
Paralysis attacks
Dizziness
Often or severe headaches
Migraine headaches
Nervous Breakdown
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
SKIN
Previous skin cancer
Melanoma
NO
NO
YES
YES
B&J
Arthritis or rheumatism
Carpal Tunnel Syndrome
Fibromyalgia
Myasthenia Gravis
Multiple Sclerosis
HEMO
Anemia (low blood)
Have you ever experienced any unusual
bleeding after surgery or dental work?
Are you or any family member a
free bleeder?
BREASTS
Pain in breasts
NO YES
Bloody nipple discharge
NO YES
Change in breast skin
NO YES
Breast mass
NO YES
Breast biopsies
NO YES
How Many? _____________________
Cancer of the breast
NO YES
Family members’ w/breast cancer
_______________________________________________
Are you or might you be pregnant now
WOMEN ONLY :
Previous mammogram
NO YES
Date of last mammogram ___________________________
NO
YES