Name: ___________________________ Date of Birth: _________________________

DETAILED PATIENT INFORMATION

Please list any medical problems/ diseases that you have:

______________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ ______________________________________________________________ _______________________________

Please list all medications, herbs, vitamins and over-the-counter products you are taking:

Name Dose/Strength How often you take it

790 Church Street, Suite 250, Marietta GA 30060 Ph: 678-797-8201 Fax: 678-290-8325

Name: ___________________________ Date of Birth: _________________________

Please list all allergies to medications, foods, chemicals, plants and the reactions you have:

Allergy Reaction

FAMILY HISTORY

Please list all family members including mother, father, sisters, and brothers: Check here if adopted

Family member

Name Medical Problems Age Deceased

Any diseases/illnesses that run in the family (Cancer, Diabetes, Heart Disease, etc):_____________________________ __________________________________________________________________ __________________________________________________________________ _____________________________________

2

Name: ___________________________ Date of Birth: _________________________

SURGICAL HISTORY

Please list all surgeries or procedures you have had done:

Date Type of Surgery/Procedure

Reason for Procedure

Hospital Name of Surgeon

Please list all medical specialists that you see:

Name of Doctor Specialty

3

Name: ___________________________ Date of Birth: _________________________

SOCIAL HISTORY

Name: _________________________ Date of Birth: _______________________Birthplace: ______________________ Level of education completed: __________What you do for work: ____________________________________________________

Marital StatusCurrent status: Divorced Married Single WidowedDo you live alone: Yes NoPreviously widowed: Yes No Previously divorced: Yes No

Children Yes NoNumber of sons: ________________ Number of daughters: ___________________

TobaccoAre you a smoker: Yes No Former Passive smoker exposure: Yes NoType: _______________________ Packs/day ___________________________Years smoked: ______ Year Quit: _____ Ever tried to quit: Yes No

CaffeineDo you drink caffeine: Yes NoType: Chocolate Coffee Soda Tablets Tea

AlcoholDo you drink alcohol: Yes No Formerly Year Quit: ________Type: Beer Hard Liquor WineFrequency: ____________ Amount: ___________ Last drink: _______________

LifestyleActivity level: Sedentary Moderate VigorousHealth club member: Now Previously NeverType of exercise: __________________________________________________________Exercise Frequency: _______________________ Hours/week: ___________________Hobbies/Activities: ________________________________________________________Specific type of diet: Low fat Low carb Diabetic Weight watchersAnimals in the home Yes No Type: __________________________Are you the one who cleans up after the animal: Yes No

4

Name: ___________________________ Date of Birth: _________________________

Recent TravelAny recent travel out of the state Yes No Where: ________________________Any recent travel out of the country Yes No Where: ________________________

SafetyAre there smoke detectors in the home? Yes NoAre there carbon monoxide detectors in the home? Yes NoIs there radon in the home? Yes NoDo you have firearms in the home? Yes NoDo you wear a seatbelt? Yes No

Advanced Directives in PlaceMark the advanced directives that you currently have in place: None DNR Living Will Durable Power of Attorney HC ProxyDo you agree to a transfusion? Yes No

5

Name: ___________________________ Date of Birth: _________________________

HEALTH MAINTENANCE

Please fill in the date of your most recent health maintenance event (if applicable):

Event Date of LastColonoscopy/ GI procedureStress test/ Cardiac procedureEchocardiogramEye examSkin examMammogram/ Breast examPap-smearPSA/ Prostate examRectal exam/ Stool cards/ FOBTBone Density

Vaccine/ Immunization Date of LastTetanus (Td)Pneumonia vaccineFlu vaccineHepatitis A vaccineHepatitis B vaccineTB/ PPD (Tuberculosis screening)MMR (Measles, Mumps & Rubella)Zostavax

Infectious Disease History

Do you have any history of blood/ blood product transfusion? If so, when and for what reason? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name: ___________________________ Date of Birth: _________________________6

Do you have any history of tick bites, Lyme disease, Rocky Mountain Spotted Fever, or Ehrlichiosis? If so, please explain:___________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever had a positive PPD test (Tuberculosis screening)? If so, what happened as a result of that positive test?___________________________________________________________________________________________________________________________________________________________________________________________________________________________

Any concern for possible HIV infection? If so, please explain:___________________________________________________________________________________________________________________________________________________________________________________________________________________________

Gynecological History (Females)

Number of Pregnancies

Number of Premature Births

Number of C-Sections

Number of Vaginal Births

Number of Life Births

Number of Births at Term

Number of Children Currently Living

Number of Ectopic Pregnancies

Number of Miscarriages

Number of Abortions

Check here if currently pregnant

7

Name: ___________________________ Date of Birth: _________________________

REVIEW OF SYSTEMS

Have you experienced any of the following symptoms in the past month?

Activity change No

Yes

Chills No YesDecreased appetite No YesFatigue No YesFever No YesInsomnia No YesIrritability No YesMalaise/ feeling unwell No YesNight sweats No YesAbnormal paleness No YesWeakness No YesWeight gain No YesWeight loss No Yes

CONSTITUTIONAL HEENT continued…Radical keratotomy No YesLasik No YesLast eye examEar discharge No YesCerumen/ ear wax No YesEar fullness No YesHearing loss No YesNoise exposure No YesEar pain No YesTinnitus/ ringing in the ears No YesVertigo/ dizziness No Yes

8

Decreased smell No YesNasal discharge/ drainage No YesNose bleeds No YesFacial pain No YesInfections No YesNasal congestion No YesSneezing No Yes

HEENT NOSE AND SINUSHeadache N

o Yes

Eye burning No YesDouble vision No YesEye discharge/ drainage No YesEye dryness No YesForeign body sensation No YesEye itching No YesRapid eye movements No YesEye pain No YesSensitivity to light No YesEye redness No YesVisual halloes or blind spots No YesSpots/ floaters No YesTearing N

o Yes

Glasses No YesContacts No YesVisual Loss No Yes

9

Name: ___________________________ Date of Birth: _________________________

THROAT AND MOUTH VASCULARTaste change No YesVoice change No YesCold sores No YesDifficulty swallowing No YesHoarseness No YesLump sensation No YesPain when swallowing No YesPost nasal drip No YesSore tongue/ tongue lesions No YesSore throat No YesTooth pain/ dentures/ plates No Yes

RESPIRATORY/ THORAX GASTROINTESTINAL

CARDIOVASCULARChest pain No YesShortness of breath at rest No YesShortness of breath on exertion No YesSleep sitting up to breathe No YesShortness of breath at night- causes awakening

No Yes

Swelling of hands and legs No YesNighttime urination No YesPalpitations/ rapid heart beat No YesPassing out No Yes

Cramping in legs when walking No YesBlueing of the hands/ feet No YesFlushing or redness of hands/ feet No YesCool extremities No YesSwelling of hands, feet or legs No YesPain in extremities No YesUlcers in legs, feet and arms No YesVaricose veins No YesBlood clots No Yes

Abdominal mass/ growth No YesAbdominal pain No YesAltered bowel habits- change from normal

No Yes

Not eating or poor appetite No YesBlack, tarry stools No YesBloating and feeling of fullness No YesBlood in stool No YesConstipation No YesDiarrhea No YesDifficult or painful swallowing No Yes

Rapid breathing No YesCough No YesChest pain No YesFrequent respiratory infections

No Yes

Coughing up blood No YesKnown TB exposure No YesPositive PPD/ TB test No YesPain with breathing “stitch” No YesShortness of breath No YesWheezing No Yes

Flatulence/ gas No YesJaundice/ yellow/ history of hepatitis

No Yes

Indigestion/ heartburn No YesThrowing up blood No YesNausea No YesWeight loss No YesHemorrhoids No YesRectal bleeding No YesReflux No YesVomiting No Yes

10

Name: ___________________________ Date of Birth: _________________________

GENITOURINARY WOMEN TO COMPLETE

METABOLIC/ ENDOCRINEVoice changes N

oYes

Cold intolerance/ feeling cold

No

Yes

Heat intolerance/ feeling hot

No

Yes

Hair loss No

Yes

Coarse hair No

Yes

Abnormal glucose/blood sugar tests

No

Yes

Abnormal fat distribution No

Yes

Abnormal hair distribution No

Yes

Chronically overweight No

Yes

Chronically underweight No

Yes

Darkening of skin No

Yes

History of gout N Ye

Back pain/ flank/ side pain No YesChange in urine color/ cloudy urine

No Yes

Urgency to urinate No YesDecreased stream or low urine output

No Yes

Pain when urinating No YesFoul urine odor No YesUrinating frequently No YesMass in groin No YesBlood in urine No YesHesitancy or difficulty urinating

No Yes

Urine leakage/ incontinence No Yes

Age of first periodLast menstrual periodFrequency of menstrual cyclesAre you post-menopausal? No YesAre you on hormones? No YesHave you previously used hormones?

No Yes

Have you ever used birth control? No YesHave you ever had an abnormal pap?

No Yes

Do you do self breast exams? No YesLack of libido No YesNipple discharge No YesBreast lumps No YesPain with sexual intercourse No YesHistory of uterine fibroids No YesProblems with infertility No YesOvarian cysts No YesSexual dysfunction No YesVaginal itching No YesVaginal discharge No Yes

History of passing a kidney stone

No Yes

Urgency to urinate No Yes

11

o sExcessive perspiration No YesExcessive hunger or thirst No YesGeneralized weakness No YesGestational diabetes No YesGoiter No YesGynecomastia/ male breast enlargement

No Yes

Low sugar reactions No YesIncrease in size of feet/ hands No Yes

MEN TO COMPLETEAre you circumcised? No Yeserectile pain No YesPenile discharge No YesBlood in your stream No YesScrotum/ testicular pain No YesScrotum/ testicular mass No YesHydrocele/ fluid around testes No YesHistory of Herpes Genitalia No YesProblems with fertility No YesHave you ever been treated for a sexually transmitted disease?

No Yes

Describe your sexual function Normal Decreased

12

Name: ___________________________ Date of Birth: _________________________

NEURO/ PSYCHIATRIC MUSCULOSKELETAL

HEMATOLOGIC

IMMUNOLOGIC

DERMATOLOGIC

13

Language disorder/ Difficulty talking

No

Yes

Unclear pronunciation No YesFocal weakness No YesDifficulty walking No YesHeadaches No YesIncontinence No YesIn-coordination No YesLightheadedness/ dizziness No YesLoss of consciousness/ fainting

No Yes

Memory loss No YesTingling/ numbness No YesSeizures No YesSpeech changes No YesTremors No YesVertigo/ Hx of Meniere’s No YesVisual changes No YesLack of concentration No YesDo you have any anxiety? No YesDo you feel fearful? No YesDo you feel excessively happy?

No Yes

Do you feel paranoid? No Yes

Back pain- neck, mid, low back No YesBone/ joint swelling or pain No YesHands/ wrist/ elbow shoulder/ hips/ feet/ ankle swelling or pain

No Yes

Muscle pain/ weakness No Yes

Easy bruising No YesEasy bleeding No YesHistory of blood clots No YesAnemia or low blood count No YesSwollen lymph nodes No Yes

Asthma No YesHay fever No YesHives No YesAnaphylaxis No YesContact dermatitis/ rashes/ metal allergy

No Yes

Food allergies No Yes“Bee” sting allergy No Yes If yes, reaction type:Environmental allergies: pollen, pollution

No Yes

Animals at home No YesAnimals in the work place No YesChemicals in the home No Yes If yes, type:Chemicals in the work place No Yes If yes, type:

Acne No YesContact allergies No YesHx of excessive sun exposure No YesFrequent skin infections No YesHair loss No YesWomen: facial hair No YesNail changes (brittle) No YesChange in skin color No YesSevere itching No YesExcessive sweating No YesSensitivity to light No YesRash No YesSkin lesions: tags, moles, freckles, birthmarks

No Yes