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Form # ENDOCRIN-2792 –FFE
Orig 09/09
Comprehensive Patient History Form
Page 1
Patient Name:_________________________________
DOS:_________________ DOB: _____________
Describe your main problem ____________________________________________________________________________________
Where is your problem located?____________________________________________
How severe is your problem? ______________________________________________
How long have you had this problem?________________________________________
When does this problem occur?_____________________________________________
Where were you when this problem started? __________________________________
What other symptoms happen with this
problem?__________________________________
______________________________________________________________________
List previous hospitalizations/Surgeries/Serious Injuries
When?
What makes this problem worse or better? ____________________________________
________________________________________________ ____________________
______________________________________________________________________
________________________________________________ ____________________
________________________________________________
____________________
________________________________________________
____________________
________________________________________________
____________________
________________________________________________
____________________
Have you ever had the following?
Diabetes……………….
Hypertension………….
Cancer…………………
Stroke………………….
Heart trouble…………..
Arthritis/gout………….
Convulsions……………
Bleeding tendency……..
Acute infections………..
Venereal disease……….
Hereditary defects……...
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
no
no
no
no
List Medications you are currently taking
1)_____________________________
2)_____________________________
3)_____________________________
4)_____________________________
5)_____________________________
Patient Social History
6)_____________________________
Marital Status:
❏ Single ❏ Married ❏ Separated ❏ Divorced ❏ Widowed
7)_____________________________
Use of alcohol:
❏ Never ❏ Rarely ❏ Moderate ❏ Daily _________________
8)_____________________________
Use of tobacco: ❏ Never ❏ Previously but quit ❏ Current packs per day ______
9)_____________________________
❏ Never ❏ Type/Frequency_____________________________
10)____________________________
Use of Drugs:
Excessive exposure at home or work to: ❏ Fumes ❏ Dust ❏ Solvents
❏ Noise
❏ Chemicals
Family Medical History
Age
Diseases
If Deceased, Cause of Death
Father
_____
________________________________________________________ ____________________________
Mother
_____
________________________________________________________ ____________________________
Siblings
_____
________________________________________________________ ____________________________
_____
________________________________________________________ ____________________________
Spouse
_____
________________________________________________________ ____________________________
Children
_____
________________________________________________________ ____________________________
_____
________________________________________________________ ____________________________
_____
________________________________________________________ ____________________________
_____
________________________________________________________ ____________________________
Page 2
Form # ENDOCRIN-2792-FFE Orig 10/09
PLEASE ANSWER ALL QUESTIONS
Have you had any of the following during the past three months?
CONSTITUTIONAL
Good general health lately……………………..
Recent weight change………………………….
Fever…………………………………………...
Fatigue…………………………………………
Headaches……………………………………...
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
EYES
Eye disease or injury…………………………..
Wear glasses/contact lens……………………..
Blurred or double vision………………………
Glaucoma……………………………………...
No
No
No
No
Yes
Yes
Yes
Yes
ENT
Hearing loss…………………………………...
Ringing in the ears…………………………….
Earaches or drainage…………………………..
Sinus problems………………………………...
Nose bleeds……………………………………
Mouth sores……………………………………
Bleeding gums…………………………………
Bad breath or bad taste………………………...
Sore throat or voice change…………………….
Swollen glands in neck…………………………
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CARDIOVASCULAR
Heart trouble……………………………………
Chest pains……………………………………..
Sudden heart beat changes……………………..
Swelling of feet, ankles or hands………………
No
No
No
No
Yes
Yes
Yes
Yes
RESPIRATORY
Frequent coughing……………………………...
Spitting up blood……………………………….
Shortness of breath……………………………..
Asthma or wheezing……………………………
No
No
No
No
Yes
Yes
Yes
Yes
GASTROINTESTINAL
Loss of appetite…………………………………
Change in bowel movements…………………..
Nausea or vomiting…………………………….
Frequent diarrhea……………………………….
Painful bowel movements or constipation……..
Blood in stool…………………………………..
Stomach pain……………………………………
No
No
No
No
No
No
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 – # pregnancies _____ # miscarriages ______
Female – date of last pap smear ___________________
Female – findings of last pap smear ❏ Normal ❏ Abnormal
Date: ______________________
Patient Signature: ___________________________________
MUSCULOSKELETAL
Joint pain……………….………………………
Joint stiffness or swelling………………………
Weakness of muscles or joints…………………
Muscle pain or cramps…………………………
Back pain……………………………………….
Cold extremities………………………………...
Difficulty in walking……………………………
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
SKIN
Rash or itching………………………………….
Change in skin color……………………………
Change in hair or nails………………………….
Varicose veins…………………………………..
Breast pain………………………………………
Breast lump……………………………………..
Breast discharge…………………………………
No
No
No
No
No
No
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………………………
Nervousness…………………………………….
Depression………………………………………
Sleep problems………………………………….
No
No
No
No
Yes
Yes
Yes
Yes
ENDOCRINE
Grandular or hormone problem…………………
Thyroid disease…………………………………
Diabetes…………………………………………
Excessive thirst or urination……………………
Heat or cold intolerance………………………..
Dry skin………………………………………...
Change in hat or glove size…………………….
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
HEMATOLOGIC/LYMPHATIC
Slow to heal after cuts………………………….
Easily bruise or bleed…………………………..
Anemia………………………………………….
Phlebitis…………………………………………
Past transfusion…………………………………
Enlarged glands…………………………………
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
ALLERGIC/IMMUNOLOGIC
History of skin reaction or other adverse reactions to:
Penicillin or other antibiotics………… No
Yes
Morphine, Demerol or other narcotics.. No
Yes
Novocaine or other anesthetics………. No
Yes
Aspirin or other pain remedies………. No
Yes
Tetanus antitoxin or other serums…… No
Yes
Iodine, methiolate or other antiseptic… No
Yes
Other drugs/medications ______________________________
__________________________________________________
Known food allergies _________________________________
Physician Signature: ______________________________________