PAST MEDICAL HISTORY LAST NAME __________________________ CHART NUMBER ______________________
Have you ever had high blood pressure? ___yes ___no For how long?___________ Current treatment _________ Have you ever had high cholesterol? ___yes ___no For how long?_____________ Current treatment __________ Do you know the number of your last cholesterol reading? ______ Total ____Triglycerides _____HDL ______LDL Do you have or ever had diabetes? _____yes ______no For how long?__________ Current treatment__________ Have you ever smoked? _____yes _____no _______Cigarettes _________packs per day ___________number of years ____________quit date _______Cigars _________number per day ___________number of years ____________quit date _______Pipe _________amount ___________number of years ____________quit date Please list all of the medications that you take, including the dose and schedule, including aspirin and vitamins. MEDICATION DOSE FREQUENCY
Have you ever had a reaction to x-ray dye? _______________When and where?______________________________ What kind of reaction did you have?___________________________________________________________________
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List any food, drug, or seasonal allergies: _________________________________ Type of reaction__________________________________________________ _________________________________ Type of reaction __________________________________________________ _________________________________ Type of reaction __________________________________________________ Please list all the surgeries you have had: DATE SURGERY WHAT HOSPITAL
Do you have any other medical problems that required hospitalization? (accidents, cancer, radiation therapy, chemotherapy, bleeding . . . . ) DATE LENGTH OF STAY WHAT HOSPITAL REASON FOR ADMISSION
Do you have any other medical problems that have not required hospitalization?
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FAMILY HISTORY:
Mother Father Sister Sister Sister Brother Brother Brother
Age ___ ___ ___ ___ ___ ___ ___ ___
Health _____ _____ _____ _____ _____ _____ _____ _____
Cause of death _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________
Does anyone on your mother’s side of the family have heart disease or diabetes?_____________________________ Does anyone on your father’s side of the family have heart disease or diabetes?______________________________ SOCIAL/PERSONAL HISTORY _______Married ________Widowed ___________Single ___________Divorced Your current occupation _____________________________ Past occupation_________________________________ Have you ever had industrial exposure (cotton dust, asbestos, Benzene, or other)?____________________________ Spouse or significant other’s name______________________________ Age_______ Health____________________ Occupation of spouse or significant other________________________________________ Number of children______________ Ages ____________ ____________ ____________ ____________ How many are living at home?__________________________ Military Service_______________________________________________________ Your Height __________ Current weight _________ Greatest weight__________ Lowest weight ________ Health _____________________ Health _____________________ Health _____________________ Health _____________________
Current diet _______________________________________________ Do you ever drink the following? ____________coffee ____________ tea ____________colas ____________Alcohol __________cups per day __________glasses per day __________glasses per day __________type _____________________amount per day
Have you ever used drugs? ______yes _______no What type__________________ Quit date_______________
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REVIEW OF SYSTEMS Please check if you have had any of the following: Use the space at the right for explanation. SYSTEM PAST PRESENT
SKIN Bruising Long term skin disease Numbness Swelling Arthritis, painful joints Back trouble Leg cramps Leg cramps with exercise Headaches Dizziness Concussion Fainting spells Ringing in ears Bleeding or discharge from ears Impaired hearing Impaired vision Cataracts Glaucoma Nose bleeds Rheumatic fever Heart murmur Heart attack Congestive heart failure Enlarged heart Chest pain Irregular heart beat Pacemaker Hoarseness Cough Cough up any blood Short of breath Pneumonia Wheezing Asthma Hayfever Bronchitis Emphysema Tuberculosis Pleurisy Difficulty swallowing Recent weight change in last six months Hiatal hernia Ulcer Heartburn Liver disease Hemorrhoids Constipation Rectal bleeding Blood in the stool Diarrhea Hepatitis
EXTREMITIES
HEAD
EARS
EYES NOSE
HEART
RESPIRATORY
GI
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GU
NEUROMUSCULAR
ENDOCRINE
HEMATOLOGY
Vomited blood Abdominal pain Upper GI series, where and when; results Gallbladder ultrasound, where and when; results Endoscopy; where and when; results Blood in urine Kidney stones Kidney infection Difficulty or pain with urination Frequency in urination Venereal infection Bladder infection Waking up at night to urinate Convulsions Stroke Depression Anxiety Eating disorder Chronic pain Hormone imbalance Hormone supplements Thyroid trouble Anemia Blood transfusion Blood disorder Phlebitis
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__________________________ DATE
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