COMPREHENSIVE PATIENT HISTORY FORM
Patient Name: _________________________________________
Date: ___________________
Describe your main problem __________________________________________________________________
Have you ever had the following?
Where is your problem located? ___________________________________
Diabetes……………….. yes no
How severe is your problem? _____________________________________ Hypertension…………... yes no
How long have you had this problem? ______________________________ Cancer……………….… yes no
Stroke………………….. yes no
When does this problem occur? ___________________________________ Heart trouble…………... yes no
Where were you when this problem started? _________________________ Arthritis/gout…………... yes no
Convulsions……………. yes no
What other things happen with this problem? ________________________ Bleeding tendency………yes no
_____________________________________________________________ Acute infections…………yes no
Venereal disease…………yes no
Hereditary defects……….yes no
List previous hospitalizations/Surgeries/Serious injures
When
List medications you are currently
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____________
taking:
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1) ______________________
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2) ______________________
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3) ______________________
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4) ______________________
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5) ______________________
6) ______________________
Patient Social History
Marital Status: ___Single___Married___Separated___Divorced___Widowed
Use of alcohol: ___Never___Rarely___Moderate___Daily
Use of tobacco: ___Never___Previously but quit___Current packs/day_____
Use of Drugs: ___Never___Type/Frequency__________________________
7) ______________________
8) ______________________
9) ______________________
10) ______________________
Excessive exposure at home or work to:___Fumes___Dust___Solvents ___Noise
Family Medical History
Age
Diseases
If Deceased, Cause of Death
Father ____________
Mother ___________
Siblings___________
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Spouse ____________
Children___________
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PLEASE ANSWER ALL QUESTIONS
Are you currently experiencing any of the following?
CONSTITUTIONAL
Good general health lately………………..
Recent weight gain……………………….
Fever………………………………………
Fatigue…………………………………….
Headaches…………………………………
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
EYES
Eye disease or injury……………………….. No
Wear glasses/contact lenses…………………No
Blurred or double vision…………………….No
Glaucoma……………………………………No
Yes
Yes
Yes
Yes
ENT
Hearing loss………………………………….No
Ringing in the ears…………………………...No
Earaches or drainage…………………………No
Sinus problems……………………………….No
Nose bleeds…………………………………..No
Mouth sores………………………………….No
Bleeding gums……………………………….No
Bad breath or bad taste………………………No
Sore throat or voice change…………………..No
Swollen glands in neck……………………….No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CARDIOVASCULAR
Heart trouble………………………………….No
Chest pain……………………………………..No
Sudden heart beat changes……………………No
Swelling of feet, ankles or hands………….….No
Yes
Yes
Yes
Yes
RESPIRATORY
Frequent coughing…………………………….No
Spitting up blood……………………………...No
Shortness of breath……………………………No
Asthma or wheezing…………………………..No
Yes
Yes
Yes
Yes
GASTROINTESTINAL
Loss of appetite……………………………….No
Change in bowel movements…………………No
Nausea or vomiting…………………………...No
Frequent diarrhea……………………………..No
Painful bowel movements or constipation……No
Blood in stool…………………………………No
Stomach pain…………………………………No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
GENITOURINARY
Frequent urination…………………………….No
Yes
Burning or painful urination…………………..No
Yes
Blood in urine…………………………………No
Yes
Change of force of strain when urinating……..No
Yes
Incontinence or dribbling……………………..No
Yes
Kidney stones…………………………………No
Yes
Sexual difficulty………………………………No
Yes
Male – testicle pain…………………………….No Yes
Female – pain with periods…………………….No Yes
Female – irregular periods…………………….No
Yes
Female – vaginal discharge……………………No Yes
Female - # of pregnancies ____# of miscarriages ____
Female – date of last pap smear____________________
Female – findings of last pap smear ___Normal ___Abn.
MUSCULOSKELETAL
Joint pain……..…………..
No
Joint stiffness or swelling…
No
Weakness of muscles or joints…….No
Muscle pain or cramps…….………No
Back pain………………………….No
Cold extremities…………………...No
Difficulty in walking………………No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
SKIN
Rash or itching……………………..No
Change in skin color………………..No
Change in hair or nails…………...…No
Varicose veins………………………No
Breast pain………………………….No
Breast lump…………………………No
Breast discharge…………………….No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
NEUROLOGICAL
Frequent or recurring headaches ……No
Light headed or dizzy….………….…No
Convulsions or seizures……………...No
Numbness or tingling sensations ……No
Tremors………………………...........No
Paralysis……………………………..No
Stroke………………………………..No
Head injury…………………………..No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
PSYCHIATRIC
Memory loss or confusion……..……No
Nervousness………………………...No
Depression…………………………..No
Sleep problems……………………...No
Yes
Yes
Yes
Yes
ENDOCRINE
Glandular or hormone problem……..No
Thyroid disease……………………..No
Diabetes…………………………….No
Excessive thirst or urination………..No
Heat or cold intolerance…………….No
Dry skin……………………………..No
Change in hat or glove size………....No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
HEMATOLOGIC/LYMPHATIC
Slow to heal after cuts…………….No
Easily bruise or bleed……………...No
Anemia………………………….…No
Phlebitis……………………………No
Past transfusion……………………No
Enlarged glands……………………No
Yes
Yes
Yes
Yes
Yes
Yes
ALLERGIC/IMMUNOLOGIC
History of skin reaction or other adverse
reactions to:
Penicillin or other antibiotics………No
Morphine, Demerol, other narcotics No
Novocaine or other anesthetics…….No
Tetanus antitoxin or other serums…No
Iodine, merthiolate, other antiseptic No
Known food allergies: _________________
Yes
Yes
Yes
Yes
Yes
PATIENT: Sign here ______________________________
PHYSICIAN: Sign here ____________________________