NAME:
D.O.B:
OCCUPATION:
HT:
WORK PHONE:
WT:
DATE:
HOME PHONE:
BP:
TPR:
What is your main reason for seeing the Doctor?
Do you have any of the following?
Do any blood relatives have any of the following?
Diabetes:
Diabetes:
Thyroid:
Thyroid:
Cancer:
Cancer:
Heart Disease:
Heart Disease:
Lung Disease:
Lung Disease:
Stomach Disease:
Stomach Disease:
Bladder Disease:
Bladder Disease:
Other:
Other:
ALLERGIES to medications:
HOSPITALIZATIONS/SURGERIES
Hives? ___Yes ___ No Swelling? __Yes __ No
HABITS
Do you use cigarettes? ___Yes ___No
How many per day?
Alcohol:
Blood transfusion? ___Yes ___No
EYES
Date:
HEART & CIRCULATION
LUNGS/BREATHING
___Normal
___Normal
___Cough
___Contacts/glasses
___Chest Pain
___Shortness of Breath
___Cataracts/glaucoma
___Ankle Swelling
___Pain
Last exam date:
___Palpitations/rapid beats
___Sputum
___Fainting
___Wheezing
___Normal
___Dizziness
___Normal
___Pain
___Other:
EARS
___Ringing
___Hearing Loss
NOSE
___Normal
___Congestion/stuffy
___Bleeding
___Injury
THROAT
___Pain
___Normal
STOMACH/BOWELS
___Change in habits
___Nausea
URINATION
___Difficulty start or stop
___Painful to urinate
___Vomiting
___Rectal Bleeding
___Pain
___Diarrhea
___Constipation
___Normal
___Flank pain
___Frequency
___Blood in urine
___Up at night
___Normal
MUSCLE/BONES
___Pain
___Fracture/breaks
NERVOUS SYSTEM
___Headache
___Head injury/knocked out?
MENTAL STATE
___Feel blue
___Nervous
___Injury
___Other
___Normal
___Seizure
___Tingling/numbness
___Weakness
___Incoordination/unsteady
___Normal
___Memory Loss
___Confused
___Anger
___Hard to Sleep
___Normal
SKIN
___Normal
___Rashes
List medications you use regularly:
Doctor’s Notes:
REPRODUCTIVE/PERIODS