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Patient History

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					Patient Medical History
Patient Name
Prescription medication currently taking:

SS#

Date

Known Allergies

Non-prescription medication currently taking:

Date of last tetanus shot:

Date of pneumonia shot:

Family History
History Heart Disease High BP Stroke /TIA Diabetes Thyroid Family Member _____________________ _____________________ _____________________ _____________________ _____________________ History High Cholesterol Lung Disease Asthma Anemia/Blood Alzheimers Disease Family Member _________________ _________________ _________________ _________________ _________________ History Glaucoma Kidney Disease Cancer, Breast Cancer, Colon etc. Depression Family Member _______________ _______________ _______________ _______________ _______________

Social History
Married Single Do you Smoke yes Divorced Separated Widowed No # packs per day _______ Quit since _______ ___________________________________________ Occupation: Do you drink alcohol? yes No Drinks per week _____________

Personal Medical History Do you have or have you ever had any of the following? Explain.
Injury or Illness
Surgery/Hospitalization

Explain Give dates and reason if known

Eye Problems Ear Problems Sinus/Allergies Respiratory Disease (Pneumonia, Bronchitis, TB etc.) High Blood Pressure Heart Disease (Heart Attack, Chest pain etc.) Stroke / TIA Circulatory Disease Bone/Joint Disease Kidney /Bladder Problems Ulcer/Colitis/Bowel (specify) Thyroid Disease Diabetes High Cholesterol Neurological Disease Blood Disease (anemia.
Leukemia, etc.)

Skin Disease Depression / anxiety Abuse Women Only:

# Pregnancies: _____________ # Births: _______________ # Miscarriages: _______________
Present Birth control: _________________________ Last Period: __________ Last PAP: _____________

GYN Problems (tubes, ovaries)
Sexual Concerns

Men Only:
Prostate Problems
Burning or Discharge from Penis

Pain or Swelling in Testicle Difficulty with Erections Any other problems you wish to discuss with the physician:

9/30/02 Form # PP 4/401 [Patient Medical History]

Bayview Physician Services, PC


				
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