MEDICAL HISTORY FORM bronchitis

							                                                MEDICAL HISTORY FORM
                                           (All Information is confidential/Please Print)

Name _____________________________________________Date of Birth__________ _______Date __________________

Allergies to medications _________________________________________________________________________________

Previous operations and dates ____________________________________________________________________________
Other hospitalizations and dates ___________________________________________________________________________

                                      Please check if you have had any of the following

                  □Palpitations                 □Chest Pain                        □ Murmur
                  □Hypertension                 □Stroke/Heart Attack               □Shortness of Breath
                  □Bronchitis                   □Asthma                            □Irritable Bowel Syndrome
                  □Abdominal Pain               □Constipation                      □GERD
                  □Urinary Tract Infection □    □Kidney Stones                     □Urgency/Frequency
                  □Leakage of Urine             □Joint/Muscle Pain                 □Osteoporosis
                  □Fractures                    □Arthritis                         □Acne
                  □Rash                         □Scars________________             □Skin Cancer
                  □Migraines                    □Dizziness                         □Headache
                  □Epilepsy/Seizures            □Tonsillectomy                     □Hearing Loss
                  □Near Sighted/Far Sighted     □Chronic Sore Throat               □Seasonal Allergies
                  □Depression                   □Bi-Polar                          □Anxiety
                  □Insomnia                     □Hot Flashes                       □Abnormal Thirst
                  □Diabetes                     □Hepatitis                         □HIV/AIDS
                  □Blood Transfusions           □Cancer _______________
Family Medical History:                                        Office Personnel Only

Heart Disease              □
Diabetes                   □
Cancer                     □
Psychiatric                □
Birth Defects              □
Other (please describe):   □
___________________

Personal Health Habits
                    Yes         No
Smoking              □           □       Cigarettes per day:____________Years:___________________
Alcohol              □           □       Drinks per day:____________Drinks per week:_____________Occasional_________
Drug Use             □           □       Type:____________________Date Last Used:______________

Birth Control History:
□Tubal      □Condoms /Spermacide      □ Vasectomy □ IUD/Hormonal IUD □ Nuva Ring □ Depo-provera
□ Diaphragm □ Oral Contraceptive □ Other ______________________________________________________________
Current Contraceptive Method: ____________________________________________Start Date:________________________


Pregnancies: _______ Miscarriages:________Abortions:________Tubal/Ectopic Pregnancies:________C/Section ____________


                                                                      NOTES
                                                              Ob/Gyn History

LMP ____________ Age periods began _________

Are Your Periods Regular ?     □ Yes □ No       _______________________________________________________

How many days do you bleed? ___________Cycle Length _____ Is the flow               □ Light     □ Medium      □ Heavy
Do you have       □ Premenstrual tension/PMS         □Bloating      □Cyclic Headaches                   □Nausea
                  □ Breast Discomfort       □ Blood Clots          □Cyclic Acne
                  □ cramps abdominal / low back       If yes: □Mild □Moderate □Severe

What Treatment Do You Use For Cramps?            □Over the Counter       □Prescription      □ Herbal      □Hot Pack

Genitourinary:   □ Yeast Infections     □ B/V           □ Vaginal Discomfort/Pain □Uterine Fibroids              □Ovarian Cysts
                 Date of Last Pap: ___________      Have you had:   □ Abnormal Pap □ Colposcopy                □ Leep
                 □ other:______________________
Breasts:         □Fibrocystic Breasts   □ Breast Cancer           □ Implants     □ Other _________________
STDs:   □Chlamydia_________ □HIV________ □Herpes_______□Genital Warts__________
        □Gonorrhea_________ □Trichomonas________□Syphilis________□ Other:_____________

                 Please list all medications you are currently taken & any you have taken in the last 30 days


    MEDICATION               DO S E      HOW OFTEN          REASON                START DATE               STOP DATE

 Sample:                   Two tabs/
  Extra Strength Tylenol    500mg        As needed          Headache                  5/30/08                 5/31/08

 Sample:
    Vitamins                 1 tab          daily         Dietary supplement         2000                       Cont.




_______________________________________________________
Patient Signature                                Date


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Coordinator Signature                            Date                    PI/Sub I Signature                               Date