DATABASE
PLEASE COMPLETE ALL QUESTIONS DATE: _
NAME: MARITAL STATUS: OS OM OW OD
ADDRESS: PHONES: H W
OCCUPATION: DATE OF BIRTH:
-
FAMILY HISTORY: If any blood relative has suffered any of the follOwing, please indicate which relative
o Epilepsy o Diabetes o
Arthritis o
Alcoholism Stroke o
o Migraine o Thyroid Disease Gouto Asthma o o
High Blood Pressure
o Mental Illness o Bleed Easily n
Osteoporosis o
Heart Disease Anemia n
o Kidney Disease n cancer o
Alzheimer's Disease 0 0
PERSONAL MEDICAL HISTORY SURGERIES/YEAR
o Appendectomy 0 Breast o Cataracts o Gall Bladder
o Hernia 0 Hysterectomy o Tonsillectomy o
OTHER HOSPITAUZATONS AND PAST MEDICAL HISTORY
o TETANUS o PNEUMOVAX o FLU VAX
USTALL 1 5 9
MEDICATIONS 2 6 10 DRUG
YOU ARE NOW 3 7 11 ALLERGIES
TAKING 4 8 12
CHIEF
COMPLAINT(S) 1 2 3
HISTORY OF PRESENT ILLNESS:
MARK (C) FOR CURRENT PROBLEMS. CHECK&. INDICATE AGE WHEN YOU HAD ANY OF THE FOLLOWING:
0 Decreased Hearing 0 Swollen Ankles 0 Painful Urination 0 Numbness/Tingling Sensations
0 Ringing in Ear 0 Fainting Spells 0 Blood in Urine 0 Dizziness
0 Leg Pain When Walking 0 Overnight Urination 0 Headaches - Frequent 0 Wear Glasses/Contacts
0 Varicose Veins/Phlebitis o
More Than 2 Times 0 Arthritis/Rheumatism 0 Double or Blurred Vision
0 Loss of Appetite-Recent 0 Control in Urination 0 Back Pain-Recurrent 0 Eye Pain
0 Difficulty Swallowing 0 Decrease in Force of 0 Bone Fracture 0 Sinus Trouble
0 Indigestion or Heartburn Urination 0 Joint Injury 0 Sore Throats-Frequent
0 Persistent Nausea 0 Kidney stones 0 Gout 0 Hayfever/ Allergies
0 Persisting Vomiting 0 Venereal Disease 0 Foot Pain 0 Hoarseness-Prolonged
0 PeptiC Ulcers 0 Chronic Fatigue 0 Rashes 0 Pneumonia/Pleurisy
0 Abdominal Pain-Chronic 0 Weight Loss-Recent 0 Hives 0 Bronchitis/Chronic cough
0 Change in Bowel Habits 0 Anemia 0 Psoriasis 0 Asthma/Wheezing
0 Diarrhea 0 Bruise Easily 0 Eczema 0 Sleeping Difficulty
0 Shortness of Breath 0 Constipation 0 Cancer 0 Diverticulosis
Il On Exertion 0 Diabetes 0 Nervousness 0 Bloody/Tarry Stools
o Lying Flat 0 Thyroid Disease 0 Depression 0 Chest Pain
0 Hemorrhoids 0 Convulsions/Seizu res 0 Memory Loss 0 High Blood Pressure
0 Gall Bladder Trouble 0 Stroke 0 Moodiness, Excessive 0 Heart Murmur
0 Jaundice/Hepatitis 0 Tremor/Hand Shaking 0 Mental Illness 0 Palpitations
0 Hernia 0 Muscle Weakness 0 Irreaular Pulse 0 Urine Infections Freauent
MALES: 0 Prostate Cancer o Impotence
FEMALES: ยท0 Pain with Menstrual Flow 0 Pain/Bleeding after Sex 0 Flushing/Menopause
Date of Last Mammogram: 0 Cramps with Menstrual Flow Age of Onset:
Date of Last Pap Test: Menstrual Flow 0 Regular 0 Irregular
Date of 1st Dav of Last Period: Birth Control Method:
No. of Pregnancies: No. of Uve Births: No. of Miscarriages:
o Alcohol Oz. Day/Week _________ EXERCISEPREFERENCE:
o Smoking Cigarettes/Day
--------------
AIDS Risk:
REUGIOUS PREFERENCE:
o Coffee/Tea Cups/Day
PHYSICAL EXAMINATION DATE:
VITALS HT WT P BP RR T
GENERAL APPEARANCE
HEAD/NECK Neg/Defect EXTREM Neg/Defect .JOINTS Neg/Defect
Head, Scalp DO stwkab
Head, Scalp DO Pulses-Fem 0 0 0 Neck 00
Lids-Sclera DO Popliteal 0 0 0 Shoulders 00
Eye Muscles DO Post Tibial 0 0 0 Elbows 00
Pupils DO Dorsalis Ped 0 0 0 Wrists 00
Fundi 00 Varicose Vein DO Fingers 00
Ears 00 Pedal Edema DO Back 00
Nose/Sinus 00 GENIT/URIN DO Hips 00
Teeth/Gums DO FEMALE 00 Knees 00
Pharynx DO Vulva/Vagina 00 Ankles/Feet 00
Thyroid DO Adnexae DO NEURO 00
Neck Glands 00 Cervix DO Paralysis 00
Carotid Bruit 00 Uterus DO Gait 00
CHEST DO Uter/Recto DO Mus.Atrophy 00
Chest-Lungs 00 Pap Test Done Yes NO' Cran.Nerves 00
Heart-Apex 00 DO . Tendon Refl. DO
Heart Sounds DO MALE DO . Romberg 00
Murm/Thrill DO Genitalia 00 Babinski 00
Breast/Nipple 00 Prostate DO Sensory DO
Axil. Nodes DO Tests DO Motor 00
ABDOMEN DO DERM 00 Vibration 00
Abd. Mass 00 Skin Lesions 00 Position 00
Abd. Tend. DO Nail Beds 00 Tremor 00
Hern. Rings DO Fingers DO Rigidity 00
Ing. Node DO Toes DO 00
OTHER TESTS
ECG _____________ StoolO&P
Chest X-ray ~ Urine
Pulm. Function Hgb WBC
Mammogram -~~-~-------- Chern Profile
Blood Sugar
ASSESSMENT PLAN
0 PREVENTATIVE HEALTH PLAN
0 FPAHANDOUT
o SPECIFICS
MEDICATION
Physician's Signature
Family Practice Associates
1594 Kingsley Ave
RETURN VISIT
Orange Park, Florida 32073