Patient Medical History


Patient Name: Date:

1. PROBLEM(S) that bring you to see the doctor:  

2. Previous Medical History: (List all diseases/diagnoses)  

3. ALLERGIES: (to drugs, antibiotics, pollens and/or chemicals) Describe reaction to each.

Substance & Reaction: Substance & Reaction: 

Substance & Reaction: Substance & Reaction:  

Substance & Reaction: Substance & Reaction:

4. MEDICATIONS: (List all medications & supplements that you are currently taking).

5. SURGERIES: Inpatient & Outpatient (List the surgery/procedure, month and year (if known), and physicians name (if known).

6. HOSPITALIZATIONS: (List the cause/diagnosis, month and year (if known), and physicians name (if known).  

7. INJURIES: (List the injury, month and year (if known), and physicians name (if known).  

8. CHILDHOOD DISEASES AND VACCINATIONS: (copy of vaccination record OK)

9. LIST FOODS THAT YOU REACTED TO AS A CHILD OR NOW:

10. OB-GYN HISTORY:

a. Age at onset of menstruation: g.  Number of preterm deliveries:

b. Age that menstruation stopped: h.  Number of miscarriages:

c. First day of last menstrual period:      i.  Number of abortions:

d. Date of last pap smear:      j.  Number of living children:

e. Number of pregnancies:      k.  Ages of children:

f. Number of term deliveries:     

Patient Name:  

11.  FAMILY HISTORY

FATHER

MOTHER

OTHER IMMEDIATE FAMILY

ELABORATION?

Heart Disease

Heart Attack

Diabetes

Hyperthyroidism

Hypothyroidism

High Blood Pressure

Stroke

Epilepsy

Cancer

Tuberculosis

Emphysema

Asthma

Allergies

Liver Disease

Alcoholism

Stomach Ulcer

Duodenal Ulcer

Kidney Disease

Glaucoma

Sickle Cell Anemia

Other Anemia

Mental Illness

Suicide

Birth Defects

Genetic Disease

Other Serious Disease


12. SOCIAL HISTORY:

a. Occupation

           i. Past Occupations:

             

b.

           i. Number of times married:  

c. Smoking history:

Average number of packs per day: Number of years used:  

d. Alcohol history: (type, frequency of use, number of years used)

           i.  Beer How often?    /week /month /year How many years used?

           ii.  Wine How often?    /week /month /year How many years used?

           iii.  Liquor How often?    /week /month /year How many years used?

e.  Illicit or intravenous drug use (type, frequency of use, number of years) N/A

           i.  Substance: How many years? How often? /week /month /year        

f.  Other pertinent social history: (names of children; significant changes in job, relationships, pets, home, health, etc., that have caused stress or relieved stress.


REVIEW OF SYMPTOMS

1 .HEAD AND NECK 11. FEMALE GENITAL/BREAST

Headaches, frequent or persistent

 
Menstrual trouble
 
Neck pains
 
Breakthrough bleeding
 
Neck lumps or swelling
 
Heavy bleeding
2. EYES  
Premenstrual bleeding/spotting
 
Wear glasses
 
Birth control pill
 
Blurry vision
 
Lumps in breasts
 
Double vision/seeing double
 
Vaginal discharge
 
Seeing halos
 
Pap smear: Normal____ Abnormal____
 
Eye pain or itching
 
Breast lump(s)
 
Watering eyes
 
Discharge from nipple(s)
 
Eye trouble
 
Other breast problem
3. EARS  
Work or family problems
 
Hearing difficulties
 
Annoyed by little things
 
Earaches
 
Worries a lot
 
Drainage from ears
12. MUSCULOSKELETAL
 
Ringing or buzzing in ears
 
Aching joints or muscles
 
Motion sickness
 
Swollen joints
4. MOUTH  
Back or shoulder pain
 
Dental problems
 
Painful feet
 
Swelling on gums/jaws
 
Handicapped
 
Sore tongue
 
Lump/swelling in muscle or on bone
 
Taste changes
13. SKIN
5. NOSE and THROAT  
Skin problems
 
Congested nose
 
Itching or burning skin
 
Running nose
 
Bleed easily
 
Sneezing spells
 
Bruise easily
 
Head colds
 
Acne
 
Nosebleeds
14. NEUROLOGICAL
 
Sore throat
 
Fainting spells
 
Enlarged tonsils
 
Dizziness
 
Persistent hoarseness
 
Numbness
6. RESPIRATORY  
Convulsions
 
Wheezes or gasps
 
Change in handwriting
 
Coughing spells
 
Trembling
 
Coughing up phlegm
 
Difficulty with balance
 
Coughing up blood
 
Weakness in arms, legs, back or neck
 
Chest colds/bronchitis
 
Speech difficulty
 
Excessive sweating
15. ENDOCRINE
 
Rib pain with breathing
 
Hungry all the time
7. CARDIOVASCULAR  
Thirsty all the time
 
High blood pressure
 
Intolerant to cold
 
Low blood pressure
 
Intolerant to heat
 
Racing heart or irregular heartbeat 
 
Thyroid trouble
 
Chest pain
 
Unusually tired or sluggish
 
Shortness of breath
 
Unusually jumpy or nervous
 
Dizzy spells
16. PSYCHOLOGICAL
 
Leg cramps
 
Nervous with strangers
 
Hot flashes
 
Difficulty making decisions
 
Heart murmur
 
Lack of concentration
 
History of rheumatic fever
 
Lonely or depressed
8. DIGESTIVE  
Cries often
 
Poor appetite
 
Hopeless outlook
 
Heartburn or indigestion
 
Desired psychiatric help
 
Bloated stomach
 
Considered suicide
 
Belching 
 
Attempted suicide
 
Abdominal pain
 
Difficulty relaxing
 
Nausea
 
Frightening dreams or thoughts
 
Vomiting blood
 
Shy or sensitive
 
Difficulty swallowing
 
Dislikes
 
Constipation
 
Loses temper easily
 
Loose stools
 
Sexual difficulties
 
Black or tar-like stools
17. GENERAL
 
Gray stools
 
Weight gain
 
Pain in rectum
 
Weight loss
 
Rectal bleeding
 
Loss of interest in eating
 
Gallbladder problems
 
Swelling/Mass, armpits or groin
 
Hemorrhoids
 
Fatigue/tiredness
9. URINARY  
Generalized weakness
 
Frequency
 
Bites nails 
 
Frequency: Daytime___ Nighttime___
 
Difficulty falling asleep
 
Wet pants or bed
 
Difficulty staying asleep
 
Burning on urination
 
Can’t go back to sleep after awakening
 
Brown, black or bloody urine
 
Lack of exercise (<20 mins aerobic/day)
 
Difficulty starting urine
 
Watches a lot of TV (>1 hour/day)
 
Urgency
 
A lot of time on computer (>1 hour/day)
10. MALE GENITAL  
Feels better when on vacation (out of town)
 
Weak urine stream
 
Feels worse when on vacation (out of town)
 
Prostate problem
 
Feels same when on vacation (out of town)
 
Discharge or burning
 
Feels better when returning home from vacation or out of town
 
Lumps on testicles
 
Feels worse when returning home from vacation or out of town
 
Painful testicles
 
Feels same when returning home from vacation or out town

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Document name: Patient Medical History
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Timestamp Audit
May 25, 2021 10:00 pm CDTPatient Medical History Uploaded by Derek Lang - langnewpatient@gmail.com IP 174.108.1.127