Lincoln Internal Medicine Assoc
Last Name
First
Middle Initial
Birth-date
Home Phone
Current Problem List:
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New Allergies:
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Changes in the last year - Check all NEW problems:
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Do you frequently have severe headaches?
Does aspirin relieve them?
Spells of dizziness?
Spells of weakness in an arm or leg?
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Do you have shortness of breath?
Do you have a chronic cough?
Do you have wheezing?
Do you cough up sputum?
Have you had chest pain or tightness?
Does your heart pound or skip beats?
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Do you frequently have trouble swallowing?
Do you have stomach pain or distress?
Do you have nausea or vomiting?
D you have heartburn?
Do you suffer from constipation?
Do you have diarrhea or loose bowel movements?
Has there been a change in your bowel movements?
Blood in the stool?
Do you have loss of appetite?
Gain or loss of weight? How much? ______
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Burning when urinating?
Blood in the urine?
Trouble holding the urine?
Get up frequently at night? How much?______
Passed a kidney stone?
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MEN ONLY:
_____ Loss of sexual activity?
_____ Prostate trouble?
_____ Trouble starting urine or slow stream?
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Pain in calves of legs when walking?
Cramps in legs at night?
Swelling in the ankles?
Do you have aching or painful joints?
Swollen or reddening of joints?
Backache?
Morning stiffness?
Skin rashes or itching?
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Do you have trouble sleeping?
Are you blue or depressed?
Are you nervous or anxious?
Do you have sexual problems or questions?
Do you have family problems or concerns?
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SOCIAL HISTORY:
_____ Do you use tobacco? How much? __________
_____ Do you drink alcohol? How much? _________
_____ Do you use illicit drugs?
_____ Do you use seat belts?
_____ Do you frequently see a dentist?
_____ Do you frequently see an eye doctor?
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FAMILY HISTORY:
_____ Strokes?
_____ Heart Disease?
_____ Cancer?
_____ Diabetes?
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WOMEN ONLY:
_____ Are you still having regular monthly periods?
_____ Have you had bleeding between your periods?
_____ When was your last pap smear?
_____ Date of last menstrual period?
_____ How many days does your period last?