health history form - amazon s3 · 1414 cross street, suite 330 shiloh, il 62269 618.277.7400 phone...
Post on 28-Jun-2020
1 Views
Preview:
TRANSCRIPT
1414 Cross Street, Suite 330 Shiloh, IL 62269
618.277.7400 Phone 618.277.7422 Fax
Health History Form
Patient Name:
DOB: Age: Last Menstrual Period:DayMonth Year
Constitutional
Recent fevers/sweats
Unexplained weight loss/gain
Unexplained fatigue/weakness Respiratory
Cough/wheeze
Coughing up blood
Emphysema
Asthma
Bronchitis
Liver Disease
Jaundice
Hepatitis
Eyes
Change in vision
Glaucoma
Cataract
Blurry/double vision
Palpitation
Angina
Ears/Nose/Throat/Mouth
Difficulty hearing
Hay fever/allergies/congestion
Trouble swallowing
Voice changes
Breast
Cardiovascular
Chest pains/discomfort
Short of breath with exertion
High blood pressure
Aneurysm
Mitral valve prolapse
Defibrillator/Pacemaker
None apply
None apply
Nausea/vomiting
Pain in abdomen
Gastrointestinal
Heartburn/reflux
Blood in stool
Clay colored stool
Dark urine
Diarrhea
Constipation
Discharge: penis or vagina
Unusual vaginal bleeding
Concern with sex functions
Genitourinary
Painful/bloody urination
Nighttime urination
Arthritis
Osteoporosis
Musculoskeletal
Muscle/joint pain
Recent back pain
For additional symptoms,please write on last page.
Referring Physician:
Main reason for today’s visit:(200 characters maximum)
REVIEW OF SYMPTOMS: Have you had or still have any of the following? (Check all that apply.)
Date:DayMonth Year
DayMonth Year
None apply
None apply
None apply
None apply
Breast lumps
Axillary node lumps
Nipple discharge
Skin dimpling
None apply
None apply
None apply
Fainting
Seizures
Weakness
Neurological
Headaches
Memory loss
None apply
Depression
Psychiatric
Anxiety/stress
Sleep problems
None apply
Blood clot
Blood/Lymphatic
Unexplained lumps
Easy bruising/bleeding
None apply
Endocrine
Cold/heat intolerance
Increase thirst/appetite
Thyroid disease
Parathyroid
Diabetes
Pancreas
Adrenal
None apply
Skin
Rash
New or change in mole
Jaundice
Cancer
None apply
Liver Disease (cont.)
Cirrhosis
None apply
1414 Cross Street, Suite 330 Shiloh, IL 62269
618.277.7400 Phone 618.277.7422 Fax
MEDICATIONS: List ALL current medications (prescription, vitamins, herbal, and over the counter)
Name of medicine / Dose/mg / Frequency/time of day Name of medicine / Dose/mg / Frequency/time of day
OPERATIONS: List ALL operations and dates
Operation / Date Operation / Date
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
ALLERGIES: List ALL allergies with reactions including medications, food, and environmental
Allergy / Reaction Allergy / Reaction
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Health History Form
Patient Name:_________________________________ DOB:____/____/____ Date:____/____/____
CURRENT MEDICAL PROBLEMS: List ALL current medical problems (CHF, high cholesterol, etc.)
Medical Problem Medical Problem
1414 Cross Street, Suite 330 Shiloh, IL 62269
618.277.7400 Phone 618.277.7422 Fax
SOCIAL HISTORY:
Cigarettes
Tobacco Use
Never Current SmokerQuit Date: Packs/Day: # of Years:
Do you drink alcohol?
Alcohol Use
# of Drinks/Week:Yes No
Yes No
Yes No
Employer:
Married DivorcedWidowed
Occupation:
Years of Education/Highest Degree:
Marital Status: Single
Spouse’s/Partner’s Name:
# of Children: Ages:
Who lives at home with you?:
Drug Use
Do you use or have you used any recreational drugs?
If Yes, list drug(s) and last date used:
Have you ever used needles to inject drugs?
SOCIOECONOMICS:
Heart disease/heart attack
High blood pressure
Diabetes
Cancer
Stroke/vascular disease
Other
Health History Form
Patient Name:_________________________________ DOB:____/____/____ Date:____/____/____
FAMILY HISTORY: Has anyone in your family had the following? List relationship (ex. parent, sibling, etc.)
1414 Cross Street, Suite 330 Shiloh, IL 62269
618.277.7400 Phone 618.277.7422 Fax
Health History Form
Patient Name:_________________________________ DOB:____/____/____ Date:____/____/____
ADDITIONAL NOTES: Write any notable information not included in the form.
top related