PATIENT HISTORY FOR CONSULTING PHYSICIAN
Please fill out completely in print, we must receive this information before we can send test kit.
Last Name______________________
Street Address________________________
First Name______________________
City________________________________
Middle Name____________________
State__________ Zip +4____________
Date of Birth_____________________
Male __________ Female____________ Home Phone Number__________________
Occupation______________________
Work Phone Number__________________ Alternate Phone_______________________
List ALL MEDICATIONS you are now taking or that you usually take. Include all prescriptions from other physicians and all
medications purchased with a prescription, such as antacids, laxatives and pain medications such at Tylenol, Aspirin and Excedrin.
Please list the strength (dosage) and frequency used. (Example: Aspirin, 5 milligrams, 2 tablets every 4 hours.)
NAME OF MEDICATION, DOSAGE, INSTRUCTIONS
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DRUG ALLERGIES?
YES__________ NO__________ If yes, list below:
1.___________________________________
2.____________________________
3.___________________________________
4.____________________________
OTHER ALLERGIES?
YES_________ NO__________ If yes, list below:
1.___________________________________
2.____________________________
3.___________________________________
4.____________________________
Do you smoke? Yes/No
Number per day_________
Age began smoking________
Do you drink coffee with caffeine? Yes/No
Number cups per day___________
Do you drink alcohol? Yes/No
Number beers/day_______ Number other daily_______
CURRENT MEDICAL ILLNESS
Illness & Dates
Illness & Dates
Illness & Dates
Illness & Dates
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PAST MEDICAL ILLNESSES AND SURGERIES
Illness & Dates
Illness & Dates
Illness & Dates
Illness & Dates
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FAMILY HISTORY
Please list your family history of various problems, such as diabetes, heart disease, high blood pressure, stroke, cancer, bleeding
disorders, tuberculosis, gout, arthritis, kidney disease, convulsive disorders, suicide or other problems:
Father: If living, give age ( ) Health condition_________________________________
If deceased, age at death ( ) Cause____________________________________
Mother: If living, give age ( ) Health condition________________________________
If deceased, age at death ( ) Cause____________________________________
Siblings: Total _____
Deceased _____ Cause__________________________________
Children: Total_____ Ages: __________ Illnesses______________________________
Symptom Review: Circle any symptom you have and comment as needed
GENERAL
Weakness, Weight Loss, Feel Bad, Loss of Drive, Unexplained Weight Gain, Dryness(skin, hair, nails))
HEAD AND NECK
Lumps, Thyroid Problems, Neck Pain, Headaches (when, where, type of pain), Hoarseness
EYES
Vision Problems, Pain, Double Vision
EARS, NOSE & THROAT
Hearing Loss, Ringing in Ears, Sinus, Dizziness, Difficulty Swallowing, Hoarseness, Hay Fever
LUNGS
Shortness of Breath, Wheezing, Asthma
HEART
Palpitations, Abnormal Pulse, Swollen Ankles, Exercise Intolerance, Leg Cramps, Cold Feet, High Cholesterol, Shortness of Breath at
Night or with Exercise, Abnormal EKG, History of Elevated Blood Pressure
GASTRO-INTESTINAL SYSTEM
Abdominal Pain, Appetite Change, Gas, Bloating, Diarrhea, Change in Bowel Habits, Food Intolerance, Blood in Stool, Gall Bladder
Disorder, Heartburn, Constipation, Hemorrhoids, Ulcers, Use of Laxatives
URINARY TRACT
Up at Night to Urinate – How Often? _____, Kidney Cyst, Loss of Bladder Control, Blood in Urine, Pain, Increase Urinary
Frequency, Infections, Stones
ENDOCRINE
Diabetes, Surgery of Thyroid Gland, Graves Disease, Pernicious Anemia, History of Head or Neck Irradiation, Family History of
Thyroid Disease, Use of Lithium
FEMALE GENITALIA
Date of Last Menstrual Period, Discharge,
Abnormal Periods: Painful, Long, Short, Heavy,
Hot Flashes, Breast Pain, Breast Lump, Cold Intolerance,
Cyclic Breast Pain, Nodules of Breast, History of Breast Cancer
MUSCULAR SKELETAL JOINTS
Arthritis (where/when)_____________________________,
Back Pain, Joint Pain, Muscle Pain, Unusual Fatigue, Swollen Joints
NEUROLOGICAL
Headaches, Seizures, Stroke, Forgetfulness, Dizziness, Anxiety, Depression, Migraine, Tension, Crying Spells, Sleep Problems, Black
Out, Panic Attacks, Personality Changes, Difficulty Concentrating & Learning
DIET
How much bread do you eat daily? ___________________
What is your soda of choice?
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OTHER INFORMATION YOU WISH THE DOCTOR TO KNOW
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Revised 10-15-14
Find: Revised Kit Forms
Title: Patient History Forms