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

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ALLERGIES: List ALL allergies with reactions including medications, food, and environmental

Allergy / Reaction Allergy / Reaction

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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.