Patient Health History

Name: Date of Birth: Age:

SS #: Today's Date: Sex: Male  Height: Female 

Primary Care Physician: ______Phone Number:

Referring MD: Phone Number:

Other MD's: Name/Specialty

Pharmacy Name: Pharmacy Number:

Current problem or reason for consultation:

Do you feel you need to be linked to our social worker (counseling or financial issues)? Yes  No  PAST MEDICAL HISTORY: Please check all the boxes that apply

Allergies  Hepatitis/Liver Disease  Anemia/Blood Disorders  Hypercholesterolemia  Arthritis  Hypertension  Asthma  Irregular Heartbeat  Blood Clots  Kidney Disease  Cancer  Pancreatitis  Cataracts  Sickle Cell Disease  Colitis  Sinusitis  Diabetes  Stroke  Emphysema  Thyroid  GERD  Tuberculosis  Glaucoma  Ulcers  Heart Disease  Other: Other: Any unusual childhood infections or illnesses?

OPERATIONS: Please list year, operation and surgeon (if known) 1. 2. 3. 4. 5.

Revised 3/7/2017 1 ROUTINE CANCER SCREENING TESTS: List last date (if known) Mammogram: Breast Exam: Pap Smear/Pelvic Exam: Stool for Occult Blood: Prostate Exam/PSA:

Chest X-Ray: Colonoscopy/Sigmoidoscopy:

SOCIAL HISTORY: Marital Status:

Number of Children: Age/Sex of Children:

Spouse Name:

Spouse Occupation:

Patient Occupation:

Highest Level of Education:

Patient Lives With: Self  Child  Spouse  Parent(s)  Sibling(s)  Friend  Other  ______City of Residence: ______Have you completed an advance directive? Yes  No  Have you completed a living will? Yes  No  Smoking History Cigarettes  How Many Years? ______

Cigars  Number Per Day ______Pipe  If Quit, When? ______Alcohol History Beer  How Many Years?______Wine  How Much Per Day/Week/Month? ______Liquor  If Quit, When? ______

Recreational Drug Use  Blood Transfusions  HIV Testing 

Nutritional Supplements: ______

Revised 3/7/2017 2 ALLERGIES TO MEDICATIONS: Yes  No  NAME OF DRUG(S)/TYPE OF REACTION:

MEDICATIONS: DOSE (mg or NAME OF DRUG mcg) HOW MANY TIMES DAILY HOW LONG (MONTH/YEARS)

Vaccinations: Please provide date of last vaccination

Pneumonia: ______Flu: ______COVID-19: ______Shingles: ______

FAMILY HISTORY: Relative Age, If Living Health Problems If Deceased, Cause Father Mother Sis/Bro Sis/Bro Sis/Bro Sis/Bro Sis/Bro

Revised 3/7/2017 3 For other relatives such as grandparents, aunts and uncles: Please check all boxes that apply Anemia  Diabetes  Blood Clots  Heart Disease  Blood Disorders  Hypertension  Cancer  Stroke  Approximately 10% of cancer is hereditary. If you are concerned your family may be at risk, genetic counseling may be appropriate for you.

Would you like to discuss this with your physician?  Yes  No Do you have a Living Will?  Yes  No Do you have a Healthcare Power of Attorney?  Yes  No Would you like further information on either of the above questions?  Yes  No REVIEW OF SYSTEMS: Please check all boxes that apply FEVER  WEIGHT LOSS  FATIGUE  GENERAL CHILLS  WEIGHT GAIN  NIGHT SWEATS  HEAD HEADACHES  RINGING IN EARS  TOOTHACHE  BLACKOUTS  SINUSITIS  DOUBLE VISION  SEIZURES  POST NASAL DRIP  BLURRED VISION  DIZZINESS  SORE THROAT  CATARACTS  HEARING  HOARSENESS  GLAUCOMA  LOSS

EARACHE  SORE TONGUE  LAST EYE EXAM______BLEEDING GUMS  NOSEBLEEDS  CHEST COUGH  SHORTNESS OF BREATH  HEART MURMUR  SPUTUM  CHEST PAIN  RHEUMATIC FEVER 

COUGHING UP  PALPITATIONS   BLOOD HIGH BLOODPRESSURE WHEEZING  SWELLING OF FEET  LAST CHEST X-RAY ______BRONCHITIS  ASTHMA 

NECK LUMPS  GOITER  PAIN OR STIFFNESS 

BREAST LUMPS  PAIN  NIPPLE DISCHARGE 

ABDOMEN NAUSEA  ABDOMINAL PAIN  CONSTIPATION  VOMITING  HIATAL HERNIA  DIARRHEA  PAIN WHEN  ULCER   SWALLOWING HEMORRHOIDS DIFFICULTY  GAS   SWALLOWING BLOOD IN STOOLS INDIGESTION  BLOATING  BLACK STOOLS 

Revised 3/7/2017 4 CONTINUE REVIEW OF SYSTEMS: Please check all boxes that apply BLOOD IN  # OF PREGNANCIES ______URINE BURNING WITH  # OF MISCARRIAGES ______SPOTTING  URINATION FREQUENT  # OF ABORTIONS ______CRAMPING  URINATION DIFFICULTY STARTING TO  # OF CHILDREN ______DISCHARGE  URINATE URINARY/GYN BLADDER/ LAST MENSTRUAL KIDNEY  VAGINAL INFECTIONS  PERIOD ______INFECTIONS GETTING UP AT NIGHT TO  DURATION ______LAST PAP SMEAR ______URINATE

SENSE OF FULL  INTERVAL ______BLADDER CHANGE IN HAIR SKIN RASH  ITCHING   OR NAILS JOINT  SWELLING  NIGHT CRAMPS  NEURO- STIFFNESS MUSCULAR JOINT PAIN  BACK PAIN  VARICOSE VEINS  EASY BRUISING OR  ANEMIA  PAST INFUSION  HEMATOLOGICAL BLEEDING TRANSFUSION  REACTIONS

THYROID HOT OR COLD EXCESSIVE THIRST ENDOCRINE    PROBLEMS INTOLERANCE OR HUNGER

ANXIETY  DEPRESSION  MEMORY LOSS  PSYCHIATRIC NERVOUSNESS 

PATIENT'S SIGNATURE: ______

PHYSICIAN'S SIGNATURE: ______

Revised 3/7/2017 5