patient history by 3kQWm23H

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									                                                 New Patient History Form




Name:_________________________ Date of Birth: ____________ SS#: _________________
Chief Complaint: ________________________________________________________________
List Current Medications:                              List Current Allergies:
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Family History:                                             Do you have a family history of:
Father:     Alive  Deceased                               Heart Disease        Yes or No
    Cause of Death _____________________                    High Blood Pressure Yes or No
Mother:  Alive  Deceased                                  Diabetes             Yes or No
    Cause of Death _____________________                    Stroke               Yes or No
Siblings Total #____ #Alive____ #Deceased ____              Cancer               Yes or No
    Cause of Death : _________________                             Site ________________
    Cause of Death : _________________                      Thyroid Disease      Yes or No
    Cause of Death : _________________                      Other Disease        Yes or No
                                                            Osteoporosis         Yes or No
Review of your Body Systems: Do you   have now or have you ever had any of the following?
                             YES      NO     Please Explain
Ulcers                       ___      ___    __________________________________________________
Colitis                      ___      ___    __________________________________________________
Rectal Bleeding              ___      ___    __________________________________________________
Change in Bowel Habits       ___      ___    __________________________________________________
Black Tarry Stools           ___      ___    __________________________________________________
Heart Disease                ___      ___    __________________________________________________
High Blood Pressure          ___      ___    __________________________________________________
Chest Pain                   ___      ___    __________________________________________________
Cough Blood                  ___      ___    __________________________________________________
Shortness of Breath          ___      ___    __________________________________________________
Thyroid Disease              ___      ___    __________________________________________________
Lung Disease                 ___      ___    __________________________________________________
Cancer                       ___      ___    Site: ______________________________________________
Asthma or Emphysema          ___      ___    __________________________________________________
Hepatitis                    ___      ___    __________________________________________________
Gallbladder Disease          ___      ___    __________________________________________________
Venereal Disease             ___      ___    __________________________________________________
Kidney Stones                ___      ___    __________________________________________________
Blood in Urine               ___      ___    __________________________________________________
Epilepsy                     ___      ___    __________________________________________________
Swollen or Painful Joints    ___      ___    __________________________________________________
Nervous System Disorder      ___      ___    __________________________________________________

                                                        Revised April 18, 2011
Review of your Body Systems:
Do you have now or have you ever had any of the following?
                                      Yes     No
Depression                            ___     ___     _________________________________
Diabetes                              ___     ___     _________________________________
Stroke                                ___     ___     _________________________________
Back Disorder                         ___     ___     _________________________________
Blood Disease or Anemia               ___     ___     _________________________________

Hospitalizations:
Illness _______________________________ Year _______           Hospital   ____________________
Illness _______________________________ Year _______           Hospital   ____________________
Surgery ______________________________Year _______             Hospital   ____________________
Surgery ______________________________Year _______             Hospital   ____________________

Your Children: Number living _______ Number Deceased _______


Your Personal Habits
                                               YES        NO              Please explain
Regularly exercise (3 or 4 times/wk)           _____     _____            _____________________
Wear Auto Seat belts (90% of time)             _____     _____            _____________________
Use Illegal Drugs                              _____     _____            _____________________
Use Alcohol                                    _____     _____            _____________________
Were you ever a heavy drinker?                 _____     _____            _____________________
Use Tobacco                                    _____     _____            _____________________

With whom may we discuss your medical condition? Please list their full names and relationship.
Name                          Relationship       Name                           Relationship




Women Only-----------------------------------------------------------------------------------------------
Menstrual Period         Age at onset _____      Date of last period _____
                                  Regular  Irregular  Difficulty with periods
Pregnancies: No. of live births____ C-Sections ____ Miscarriages ____ Stillborns____ Premature _____
       Describe any complications_______________________________________________________




Patient Signature: _____________________________________              Date: ___________________

Reviewed by Doctor:     Date:                                  Reviewed by Doctor:     Date:
_________________       ____________                           ______________          __________
_________________       ____________                           ______________          __________




                                                           Revised April 18, 2011

								
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