Patient History

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PATIENT  HEALTH  HISTORY      

This  form  will  become  part  of  your  medical  record.    You  may  be  asked  to  periodically  update  this  form.     Name:_____________________________________________   Date:__________________    Family  MD:____________________________         Height:_____________   Weight:______________   Date  of  Birth:_________________   Pharmacy:__________________________     Were  you  referred  to  our  office  today?    [      ]  No    [      ]  Yes                          Who  is  the  referring  doctor?________________________________________________     What  kind  of  symptoms  are  you  having  that  you  are  seeing  the  doctor  today?  ___________________________________________________________     __________________________________________________________________________________________________________________________     How  long  have  you  had  these  symptoms?    _______________________________________________________________________________________     Do  you  wear  hearing  aids?    [      ]  No      [      ]  Yes                  If  yes,  where  did  you  obtain  your  hearing  aids?  _____________________________________________       Do  you  have  any  of  these  symptoms?     Constitutional  Symptoms:      ______None           _____  Fatigue     _____  Chills     _____  Daytime  Somnolence           _____  Fever     _____  Weight  Loss     Eyes:           ______None           _____  Eye  Pain     _____  Loss  or  blurring  of  vision         Ear,  Nose  &  Throat:       ______None           _____  Ringing  in  the  ears     _____  Dizziness     _____  Difficulty  swallowing           _____  Hearing  Loss       _____  Sinusitis     _____  Hoarseness     Cardiovascular:         ______None           _____  Chest  pain  at  rest     _____  Palpitations           _____  Chest  pain  on  exertion     _____  Swelling  of  ankles           Respiratory:        ______None           _____  Wheezing       _____  Shortness  of  breath   _____  Coughing           _____  Snoring/Apnea     _____  Coughing  up  blood     Gastrointestinal:        ______None           _____  Nausea       _____  Blood  in  stool   _____  Indigestion  and  heartburn           _____  Vomiting       _____  Abdominal  pain     Musculoskeletal:         ______None           _____  Joint  Pain     _____  Muscle  pain     Integumentary:         ______None           _____  Skin  rashes     _____  Itching     _____  Change  in  moles     Neurological:         ______None           _____  Headaches     _____  Blackouts     _____  Weakness     Psychiatric:         ______None           _____  Anxiety     _____  Depression    

 

    Endocrine:          

   

______None     _____  Excessive  intake  of  water  

_____  Heat/Cold  intolerance  

______None     _____  Abnormal  bleeding  

 

_____  Easy  bruising    

______None     _____  Itchy  eyes  

_____  Anaphylaxix    

 

Hematologic/Lymphatic:            

_____  Swelling  of  lymph  glands  

 

Allergic/Immunologic:              

 

_____  Sneezing  

 

_____  Hives  

 

 

Do  you  use  tobacco?    [      ]  No    [      ]  Yes    Please  circle  one:    cigarettes        cigars        chewing  tobacco    How  much?  _____________________________________     Have  you  ever  smoked?    [      }  No    [      ]    Yes                 If  yes,  when  did  you  quit?________________________________     If  patient  is  a  child,  is  child  exposed  to  secondhand  smoke?      [      ]    No      [      ]    Yes     Alcohol    use?    [      ]  No      [      ]  Yes              If  yes,  how  much?_________________________       Pregnant?__________    Breast  Feeding?____________     Caffeine  Intake?    [      ]  No      [      ]  Yes        If  yes,  how  much?  ______________________________     Do  you  have:   _____Anemia   _____Diabetes   _____Kidney  stones   _____Arthritis   _____Epilepsy   _____Lung  Disease   _____Bone/Joint  deformity   _____Heart  disease   _____Lupus   _____Cancer  Type  ____________________   _____High  blood  pressure   _____Migraines       _____Tuberculosis    

  Please  list  all  other  medical  problems:   1. ___________________________________________________   2. ___________________________________________________   3. ___________________________________________________   4. ___________________________________________________   5. ___________________________________________________   6. ___________________________________________________       Please  give  any  significant  family  medical  history:   1. ___________________________________________________   2. ___________________________________________________   3. ___________________________________________________   4. ___________________________________________________   5. ___________________________________________________   6. ___________________________________________________       List  all  past  surgeries:                                    List  all  medications  with  dosage:           1. ______________________________________________   1. ______________________________________________   2. ______________________________________________   2. ______________________________________________   3. ______________________________________________   3. ______________________________________________   4. ______________________________________________   4. ______________________________________________   5. ______________________________________________   5. ______________________________________________   6. ______________________________________________   6. ______________________________________________     7. ______________________________________________     8. ______________________________________________   List  all  allergies:   9. ______________________________________________   1.  ______________________________________________   10. ______________________________________________   2.  ______________________________________________   11. ______________________________________________   3.  ______________________________________________   12. ______________________________________________   4.  ______________________________________________   13. ______________________________________________   5.  ______________________________________________   14. ______________________________________________   6. ______________________________________________   15. ______________________________________________         PATIENT’S  NAME:    _____________________________________