MEDICAL HISTORY FORM MEDICAL HISTORY FORM MEDICAL by mikesanye

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									              DANE COUNTY FAMILY ACUPUNCTURE – MEDICAL HISTORY FORM


Patient Name                                                                            Date
Social Security #                                                                       Birthdate
Occupation                                                                              Height
Gender                ☐    Male     ☐    Female                                         Weight


CONTACT INFORMATION


Address                                                                                        Phone #
City, State, Zip                                                                               Work #
Email Address                                                                                  Cell #
Emergency Contact                                                                              Phone #
Physician’s Name                                                                               Phone #
Clinic Name


REASON FOR VISIT


What is the reason for today’s visit?
How long have you had this condition?
What seemed to be the initial cause?
Have you consulted your doctor?


HEALTH INSURANCE INFORMATION


Insurance Provider                                                                             Phone #
Address                                                                                        Policy #
City, State, Zip                                                                               Group #


SURGERY AND TRAUMA

                                 accidents,
Please list any major surgeries, accidents, severe blood loss, traumas, or hospitalizations.
Event                                          Date                            Describe




REPRODUCTIVE HISTORY


Age menses began                                                                          # Pregnancies
Date last period began                                                                    # Miscarriages
Age at menopause                                                                                 births
                                                                                          # Live births
Prostrate Issues            ☐Yes ☐No         Describe                                     Impotence        ☐Yes ☐No
FAMILY MEDICAL HISTORY


Please check the box next to conditions that you or an immediate family member have or have had in the past.
                                             You        Family                                                 You   Family
AIDS/HIV                                     ☐          ☐           Measles                                    ☐     ☐
Alcoholism                                   ☐          ☐           Multiple Sclerosis                         ☐     ☐
Allergies                                    ☐          ☐           Mumps                                      ☐     ☐
Appendicitis                                 ☐          ☐           Pacemaker (Date:            )              ☐     ☐
Arteriosclerosis                             ☐          ☐           Pleurisy                                   ☐     ☐
Asthma                                       ☐          ☐           Pneumonia                                  ☐     ☐
Birth Trauma (your own birth)                ☐          ☐           Polio                                      ☐     ☐
Cancer                                       ☐          ☐           Rheumatic Fever                            ☐     ☐
Chicken Pox                                  ☐          ☐           Scarlet Fever                              ☐     ☐
Diabetes (Type:                )             ☐          ☐           Seizures                                   ☐     ☐
Emphysema                                    ☐          ☐           Stroke                                     ☐     ☐
Epilepsy                                     ☐          ☐           Thyroid Disorders                          ☐     ☐
Goiter                                       ☐          ☐           Tuberculosis                               ☐     ☐
Gout                                         ☐          ☐           Typhoid Fever                              ☐     ☐
Heart Disease                                ☐          ☐           Ulcers                                     ☐     ☐
          (Type:
Hepatitis (Type            )                 ☐          ☐           Venereal Disease                           ☐     ☐
       (Type:
Herpes (Type               )                 ☐          ☐           Whooping Cough                             ☐     ☐
High Blood Pressure                          ☐          ☐           Other (Specify:                       )    ☐     ☐


CURRENT SYMPTOMS


Have you experienced any of the following symptoms in the last week?
                                                                                                               Yes   No
                                              arm,
Sudden chest pain or pain radiating down your arm, to your neck, or to your jaw.                               ☐     ☐
Sudden onset of severe diarrhea, abdominal pain, or vomiting.                                                  ☐     ☐
                                             despite
Cough that has persisted longer than 6 weeks despite evaluation and treatment.                                 ☐     ☐
        difficulty
Extreme difficulty breathing in or breathing out.                                                              ☐     ☐
 leeding
Bleeding when coughing, urinating, vomiting, during bowel movements, or from any other cause?
              coughing, urinating,                        movements,                                           ☐     ☐
Sudden onset of severe headaches.                                                                              ☐     ☐
Tenderness and swelling or redness in your calf or thigh.                                                      ☐     ☐
                redness
Sudden onset of redness in your eyes, changes in vision, blurring, flashes of light, or blind spots            ☐     ☐
Loss of consciousness, paralysis, weakness, numbness, or seizures.                                             ☐     ☐
Undiagnosed recent trauma such as a fall, accident, or head injury.                                            ☐     ☐
                                  lightheadedness.
Frequent episodes of dizziness or lightheadedness.                                                             ☐     ☐
Fever of unknown origin.                                                                                       ☐     ☐
Sudden onset of severe, undiagnosed back pain.                                                                 ☐     ☐
Sudden decrease in urinary output.                                                                             ☐     ☐

PRACTITIONER USE ONLY

								
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