HEALTH HISTORY Yolanda Marcos, M.D., P.A. Page 1/2
(CONFIDENTIAL) 510 Med Court, Suite 210, San Antonio, Texas 78258
Name _____________________________________________Today's Date ________________________________________
Age ____________ Birthdate __________________________Date of last physical examination ________________________
What is the reason for your visit? __________________________________________________________________________
SYMPTOMS Check ( ) symptoms you currently have or have had in the past year.
GENERAL GASTROINTESTINAL EYE, EAR, NOSE, THROAT MEN only
Chills Appetite poor Bleeding gums Breast lump
Depression Bloating Blurred vision Erection difficulties
Dizziness Bowel changes Crossed eyes Lump in testicles
Fainting Constipation Difficulty swallowing Penis discharge
Fever Diarrhea Double vision p
Sore on penis
Forgetfulness Excessive hunger Earache Other
Headache Excessive thirst Ear discharge
Loss of sleep Gas Hay fever WOMEN only
Loss of weight Hemorrhoids Hoarseness Adnormal Pap Smear
Nervousness Indigestion Loss of hearing Bleeding between periods
Numbness Nausea Nosebleeds Breast lump
Sweats Rectal bleeding Persistent cough Extreme menstrual pain
Stomach pain Ringing in ears Hot flashes
MUSCLE/JOINT/BONE Vomiting Sinus problems Nipple discharge
Pain, weakness, numbness in: Vomiting blood Vision ‐ Flashes Painful intercourse
Arms Hips Vision ‐ Halos Vaginal discharge
Back Legs CARDIOVASCULAR Other
Feet Neck Chest pain SKIN Date of last
Hands Shoulders High blood pressure Bruise easily menstrual period _________________
I l h tb t
Irregular heart beat Hives
Hi fl
Date of last
GENITO‐URINARY Low blood pressure Itching Pap Smear ______________________
Blood in urine Poor circulation Change in moles Have you had
Frequent urination Rapid heart beat Rash a mammogram? _________________
Lack of bladder control Swelling of ankles Scars Are you pregnant? _______________
Painful urination Varicose veins Sore that won't heal Number of children _______________
CONDITIONS Check ( ) conditions you currently have or have had in the past year.
AIDS Chemical Dependency High Cholesterol Prostate Problem
Alcoholism Chicken Pox HIV Positive Psychiatric Care
Anemia Diabetes Kidney Disease Pheumatic Fever
Anorexia Emphysema Liver Disease Scarlet Fever
Appedicitis Epilepsy Measles Stroke
Arthritis Glaucoma Migrain Headaches Suicide Attempt
Asthma Goiter Miscarriage Thyroid Problems
Bl di Di d
Bleeding Disorders G h
Gonorrhea Mononucleosis
M l i T illiti
Tonsillitis
Breast Lump Gout Multiple Sclerosis Tuberculosis
Bronchitis Heart Disease Mumps Typhoid Fever
Bulimia Hepatitis Pacemaker Ulcers
Cancer Hernia Pneumonia Vaginal Infections
Cataracts Herpes Polio Venereal Disease
MEDICATIONS List medications you are currently taking. ALLERGIES
to medications or substances.
Pharmacy Name ___________________________________________ Phone __________________
Rev. 7/23/10
Page 2/2
(ALL INFORMATION IS STRICTLY CONFIDENTIAL)
FAMILY HISTORY Fill in health information about your family.
State of Age at Check ( ) if, your blood relatives had any of the following:
Relation Age Cause of Death
Health Death Disease Relationship to you
Father Arthritis, Gout
Mother Asthma, Hay Fever
Asthma Hay Fever
Brothers Cancer
Chemical Dependency
Diabetes
Heart Disease, Strokes
Sisters High Blood Pressure
Kidney Disease
y
Tuberculosis
Other
HOSPITALIZATIONS PREGNANCY HISTORY
Reason for Hospitalization Year of
Year Hospital Birth
Complications, if any
and Outcome
HEALTH HABITS Check (
HEALTH HABITS Ch k ( ) which substances you
) hi h b t
use and describe how much you use.
Have you ever had a blood transfusion? Substance How much used
Yes No Caffeine
If yes, please give approximate dates: ___________________________ Tobacco
SERIOUS ILLNESS/INJURIES Date Outcome Drugs
Alcohol
Other:
Other:
OCCUPATIONAL CONCERNS
Check ( ) if your work exposes you to the following:
Stress
Hazardous Substances
H d S bt
Heavy Lifting
Other:
Other:
Your occupation:
y y g y y p y
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of her staff responsible for any errors
or omissions that I may have made in the completion of this form.
Signature Date
Reviewed By Date
Rev. 7/23/10