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Date of appointment: ________________________ Patient name: ____________________________________________ Date of birth: _________________ Age: ___________ Primary care provider: _____________________________________ Referring provider: ___________________________________ Reason for Visit: _____________________________________________________________________________________________ *Nurse use only: Preferred local pharmacy: _______________________________ Preferred mail order pharmacy: _______________________ Preferred laboratory for blood work: ______________________ Preferred radiology facility: ___________________________ HT _______ Weight _______ BP ______/______ Pulse ________ Immunizations: Flu/When?_____ (65 or older) Pneumovax/When?_____ Fallen within the last 3 months? ______ Fear of falling?______ Difficulty ambulating? ______ Patient Review of Systems Please mark any condition with which you have had significant problems in the last 6 months: Constitution Gastrointestinal Skin ___ Chills ___ Abdominal distention ___ Rash ___ Diaphoresis (Night sweats) ___ Abdominal pain ___ Color changes (Yellow skin) ___ Fatigue ___ Blood in stool ___ Fever ___ Constipation ___ Loss of appetite ___ Diarrhea Neurological ___ Weight loss ___ Nausea ___ Dizziness ___ Weight gain ___ Vomiting ___ Headaches ___ Black stool ___ Light-headedness HEENT ___ Change in bowel habits ___ Seizures ___ Eye pain ___ Difficulty swallowing ___ Weakness ___ Trouble swallowing ___ Gas/flatulence ___ Yellow eyes ___ Heartburn/indigestion ___ Bowel accidents Hematological Respiratory ___ Reflux ___ Enlarged lymph nodes (Adenopathy) ___ Chronic cough ___ Vomiting blood ___ Bruises/bleeds easily ___ Shortness of breath ___ Wheezing Psychiatric ___ Excessive snoring Genitourinary ___ Behavior problems (Depression) ___ Hoarseness ___ Pain on urination (Dysuria) ___ Nervous/anxious ___ Flank pain ___ Sleep disturbances ___ Blood in urine (Hematuria) Cardiovascular ___ Chest pain Musculoskeletal ___ Palpitations ___ Arthralgia’s (Joint pain) ___ Back Pain -1- Patient name: ________________________________________ Date of birth: ______________________ Immunizations: Y/N Date last received Flu Vaccine If 65 or older, Pneumococcal Vaccine Please update any new medications or allergies since we last saw you in our office: Medications: Medication Name Dose Frequency Medication Allergies: Name of allergen Reaction/Date of Onset Social History Tobacco Use: Y/N/Former Quit date: ____________ Packs/day: _________ Smokeless Tobacco: Y/N/Former Type: Chew/Snuff Quit date: __________ Alcohol use: Y/N/Former Drinks per week: ____ glasses of wine ____ cans of beer ____ shots of liquor Drug use: Y/N/Former Types: ____ marijuana ____ methamphetamine ____ cocaine ____ IV Other: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Caffeine use: Y/N/Former Amount/Day: _________ Type: _____________ -2- .

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