Patient History Form - PATIENT HISTORY

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Patient History Form - PATIENT HISTORY Powered By Docstoc
					                                          MARK P. OMBRELLARO, M.D.
                                            PATIENT MEDICAL HISTORY

NAME___________________________________________ BIRTH DATE ________________ DATE________________


  HOSPITALIZATIONS: List all medical and surgical admissions,        REVIEW OF SYSTEMS
  including dental.                                                  Do you have, or have you had, any of the following:
                                                                                                                      Yes    No
  Date       Hospital          Operation/Illness                     Abdominal pain                                   ____   ____
  _______    ______________    ____________________________          Anemia                                           ____   ____
  _______    ______________    ____________________________          Arthritis                                        ____   ____
  _______    ______________    ____________________________          Asthma                                           ____   ____
  _______    ______________    ____________________________          Backaches                                        ____   ____
                                                                     Blood in the urine                               ____   ____
  ALLERGIES: If you are allergic to any medications or foods, list   Blurred vision                                   ____   ____
  them below, along with the type of reaction.                       Breast biopsy                                    ____   ____
  ______________________________________________________             Breast lumps                                     ____   ____
  ______________________________________________________             Breast pain                                      ____   ____
  ______________________________________________________             Changes in voice                                 ____   ____
  ______________________________________________________             Chest pain with exertion (angina)                ____   ____
                                                                     Colitis                                          ____   ____
  MEDICATIONS: If you are taking any medications, list them          Coughing up blood                                ____   ____
  along with the amount of each dose and the number of times each    Diabetes                                         ____   ____
  day you take it.                                                   Diarrhea                                         ____   ____
                                                                     Epilepsy                                         ____   ____
  Name                         Dosage             Times/Day          Bleed or bruise easily                           ____   ____
  ______________________       ______________     ____________       Blood with bowel movements                       ____   ____
  ______________________       ______________     ____________       Fatigue                                          ____   ____
  ______________________       ______________     ____________       Gallbladder problems                             ____   ____
  ______________________       ______________     ____________       Glaucoma                                         ____   ____
  ______________________       ______________     ____________       Headaches                                        ____   ____
  ______________________       ______________     ____________       Heart attack                                     ____   ____
  ______________________       ______________     ____________       Heart murmur or other condition                  ____   ____
  ______________________       ______________     ____________       Heartburn                                        ____   ____
                                                                     Hemorrhoids                                      ____   ____
  HABITS:                                                            Hepatitis                                        ____   ____
  Have you smoked? Y N      How much per day?_____________           Hernia                                           ____   ____
  Age started_______________ Date quit,____________________          High blood pressure (hypertension)               ____   ____
  Do you drink alcohol? Y N If yes, how much?_____________           High cholesterol (blood fat)                     ____   ____
                                                                     Jaundice                                         ____   ____
                                                                     Kidney stones                                    ____   ____
  HAVE YOU HAD:                                                      Loss of speech                                   ____   ____
               Y/N        Date          Why                          Lumps in neck                                    ____   ____
  CAT scan     ___        __________    ____________________         Malignancies (cancer)                            ____   ____
  Ultrasound   ___        __________    ____________________         Memory difficulties                              ____   ____
  Transfusion  ___        __________    ____________________         Menstrual problems                               ____   ____
                                                                     Nausea or vomiting                               ____   ____
                                                                     Nipple discharge                                 ____   ____
  PHYSICIANS you have seen in the last 3 years:                      Pain in the feet                                 ____   ____
                                                                     Pain/cramps in legs when walking                 ____   ____
  Physician          Problem                      Last               Radiation treatments                             ____   ____
  Name               Treated                      Seen               Sexually transmitted disease                     ____   ____
  _______________    _______________________      ____________       Shortness of breath                              ____   ____
  _______________    _______________________      ____________       Stomach ulcers                                   ____   ____
  _______________    _______________________      ____________       Stroke                                           ____   ____
                                                                     Swallowing difficulty                            ____   ____
  FAMILY HISTORY: Please circle any diseases that have               Swelling in feet or ankles                       ____   ____
  occurred in your family:                                           Thyroiditis                                      ____   ____
                                                                     Tuberculosis                                     ____   ____
  Diabetes     Cancer     TB     Heart disease     Stroke            Weakness or loss of sensation in any area        ____   ____
                                                                     Weight gain or loss recently                     ____   ____
              Age    If deceased, cause and age of death
  Father      ___    ____________________________________
                                                                     For clinical use only:
  Mother      ___    ____________________________________
                                                                     Information given:_________________________________
  Sister      ___    ____________________________________
                                                                     Type_____________________________________________
  Brother     ___    ____________________________________

				
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