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Patient History


									Patient Medical History
Patient Name
Prescription medication currently taking:



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

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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