HEALTH HISTORY
ao8_---J____J-
Refenal/PCP:
Prefened Pharmacy:
ro l€P la |iEEIYOUR EflTIRE tE trtclRErtmq
(Staff use:
)
l. PAST MEDICAL
Dat€s
vrmr-s Heighr:
Fuot T r]rs Fonr oom.Eray, ru6 E A @IIFD€IIIAL
Atonr.rBEtGPr rIrEotrce
ft
tn,
welght
_tbs,
Bp:
_/_
temp:
Q Ghucona
tr Livtr
B
O Mcoingitis
casero/GBR.D
O Bladd€r Disordcc
O Hcart Murmur
O Anc€(
tr Hpcrtcosion
O CTIF
O@PD
ElHy@,,rcidism_
O Tt],toid
B kritrble bond
tr
fbbcrculoais
O Disb.t€s I/ tr
O KidDcy
O
Otcr
Plre
Iist all
)lou
rcrlxs ilh.sscs, op.tdic &
Discasc_
_
Dis€ase_
Patient denics any surgeries
hocpitalizatims you harrc trqcriraccd md ladirxc ytar rbcsc ocorrrcd
tr Adenoidectomy
D C-Sectioa
O Paceoaker
D Appendix
OGallbladd€r
B Kneo Surgory
tr Bac* Suryery
O
tleart surgery
O Stomach Surgery
OBrcrstBiq'sy
OHyskeAomy
D Tonsillectomy
D Cosmetic
tr Otter Surgeries
tr Wisdorn tmth
D
Olter Surgeries
3.
MEDICfiIONS:
Plcasc
CURRENT MEDICATTONS:
a.
_
tr Pa*insonism
. tr Scizres
tr sroke/TlA
crtr hrd rbo folbwiag:
dcr
putse:
HsroRy
Discasc
O Hc6rt Dis€ase
- H!rc
TGDrcAL
Dates
o arhritis
PAST SITRGICAL BXSf,ORy
yotn.
_RR:_
Dates
Antnt
2.
REcoRD oF
_Patient denies any PMEI
EISTORy - Hrrc Fu ctu had rhc following:
O Alcoholism
O
EEASE
Reaon for vbit
Plcaso llst alt
ILLERGIES (frod,
lig all ncdlclacs vou arc enrotly
DOSAGE (Dg)
dnrgs, aDd cavtoom€at)
ttiag
-
_
Petient denles taldry any Medlc{dons
how oftar pcr day?
Padent denles any Alleryles
5.
FAMILY HISTORY: Hss lry blood rclariw had aoy of thc following: (Chcck bo:q lcavc blank if uncatain)
Denies
ftmily history of
Reladonshio
Relationsh i o
o Brcast C{Dc€r
o lIigh Blood Pressure
o Genetic Problem
o Kidney Problem
o Seiz:re Disorder
o Colon Csmer
o GYN Caacer
o Diabetes
o Head Disease
D High Cholestcrol
o Stoke
o Thyroid Disorder
6. Mersfilal Eistory:
Age
of ld period #
Flow:
Days between period #
Medium
ligtt
Total days on pedod #
Heavy
Irst
Period
Mettod of BirtL Contol--
Clot
Mooopause Stafirs
Age Meoopause
Brcalfirugh
7.
bbcdiog Yedi,,to
_
Yesr'No
#_
Hormooe Rcirlac€m€nt
lfu.ap'l
yes /No
SOCIALEISIORY:
16vs1
!
Q asy6
fl
Tobaceo: Q
Alcoholi
minimd tr p .(-Sackdday x
yrs) tr quit
ago LJnckyd8y x
---yrs
minimrl E less fl'r" l0 per urcek
E moro tban l0 perureek
-
Illicitdrug trNo tr Yes uAar tpe:
Mrrihl stahrs: tr sin€le trEogsged tr
Maried
Flowsheot
_ fst !+ Smgu
_!:stlxa Scan
_ Irst PSA
last Mammo
-Irst
Tetarus
tr
wdoc/pd
tr Divorced e
ys)
partDor
8.
REVIEW OF SYSIEMS:
DO YOU IIAVE NOW OR IIAVE YOU EAD WA}TY OF TIIE BEIOW PROBLEM WTIIIIN THE PAST YEAR:
(Plcrsc circlc rD)/(hiog for whlct you hlve! history o0
Constitutional: fever,
ste6s,
weight
change,
Eyes:
blunrd vision,
ffiNT:
pain, headache.s,
earaches nose bleeding
ringing in the ears
Br€ase
lu-p
nipple
Cardiovasculer:
che.*
double vision
sinus
skin
irregular
Respiratory: coughing
shorhess
dianhea
sore
nstL
pain,
Gastrointestinal:
fatigue
heartbeas,
cold
6roat,
discharge,
extremities
ofbreadl uAoezing
aMominal
pain
nasal congestion,
tendemess
Short ofbreattr/ exertion
coughing up blood
nausea/vomitin& heanbum
Genifourirary: ugency frequency
painfrrl
SIdl:
itchhg
new skin lesioos
trEmors
tinglingornumbnesg incoordination
rasb,
Neurcloglcal: soia[€
Musculoskdetal:
Endocrine:
back
paiq
joint
pain
fr€quent urination,
muscle
urination
psin
excessivethirst
Psychlatric: aodety, depression
feeling confirsod
Eeme-Lymph:
swollen glands
Allerglc-
Immu:
easy
bleeding, easy bruising
sinus allergies
Signature ofPatient or par€nt
U02
if minor
constipation,
incontinence
sweillirg
cold/heatintolerance,
frequent illnesses
Date