Date:_________
NAME:_______________________
CURRENT PHONE #:_____________________________
Medical Information Sheet
Reason for today’s visit: __________________________________________________________________
Current Active Symptoms:
General:
[]Fever []Night sweats
[]Chills []Weight loss
[]swollen/enlarged lymph nodes
[]Fatigue
[]Decreased energy
Head:
[]Headaches
Sinus:
[]Pressure
Eyes:
[]Itching
[]Discharge []Swelling
Ears:
[]Itching
[]Fullness []Popping []Pain []Ringing in ear []Vertigo ~ dizziness []Discharge
Nose:
[]Pain
[]Tearing
[]Pain
[]Sneezing []Runny nose []Congestion []Nose bleeds []Post Nasal Drainage []Decreased taste
[]Decreased smell
Throat:
[]Itching
Respiratory:
[]Cough []Chest Pain/Tightness []Shortness of breath []Wheezing
[]symptoms worse at night or awaken from sleep
Cardiac:
[]Difficulty breathing lying down []Chest pain
[]Swelling of the legs or ankles []Racing heart or irregular heartbeat
Gastrointestinal:
[]Trouble swallowing []Decrease appetite []Nausea []Vomiting []Cramping []Constipation
[] Diarrhea []Abdominal pain []Reflux or heartburn
Urinary:
[]Increase in urination frequency []Painful urination []Blood in urine []Incontinence
[]Soreness []Fullness []Difficulty Swallowing []Hoarseness []Frequent infections
MS/Peripheral Vascular: []Joint Pain
[]Stiffness
[]Coughing blood
[]Muscle pain
Neuro/Psychiatric:
[]Dizziness []Weakness []Numbness or Tingling []Anxiety []Depression
Skin:
[]Itchy skin []Rash []Hives []Swelling
Smoking Status:
[] Never Smoked
[] Former Smoker
[] Current Smoker
Current Medications: ______________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you allergic to any medications: [ ] Yes [ ] No If yes, please list drug & reaction:_________________
__________________________________________________________________________________________
Primary Care Physician or Pediatrician’s name: _________________________________________________
Do you want a copy of this visit sent to the above listed physician? [ ] Yes [ ] No