<p> CONFIDENTIAL HEALTH HISTORY Name: Date: Birthdate: Age: Date of last physical examination: Occupation: Reason for visit today: MEDICATIONS List all medications you are currently taking ALLERGIES List all allergies</p><p>SYMPTOMS Check {} symptoms you currently have had in the past year. GENERAL GASTROINTESTINAL EYE, EAR, NOSE, MEN only THROAT  Chills  Appetite poor  Bleeding gums  Breast lump  Depression  Bloating  Blurred vision  Erection difficulties  Dizziness  Bowel changes  Crossed eyes  Lump in testicles  Fainting  Constipation  Difficulty swallowing  Penis discharge  Fever  Diarrhea  Double vision  Sore on penis  Forgetfulness  Excessive hunger  Earache  Other  Headache  Excessive thirst  Ear discharge WOMEN only  Loss of sleep  Gas  Hay fever  Abnormal Pap Smear  Loss of weight  Hemorrhoids  Hoarseness  Bleeding between periods  Nervousness  Indigestion  Loss of hearing  Breast lump  Numbness  Nausea  Nosebleeds  Extreme menstrual pain  Sweats  Rectal bleeding  Persistent cough  Hot flashes MUSCLE/JOINT/BONE  Stomach pain  Ringing in ears  Nipple discharge Pain, weakness, numbness in:  Vomiting  Sinus problems  Painful intercourse  Arms  Hips  Vomiting blood  Vision – Flashes  Vaginal discharge  Back  Legs CARDIOVASCULAR  Vision – Halos  Other  Feet  Neck  Chest pain SKIN  Hands  Shoulders  High blood pressure  Bruise easily Date of last menstrual period GENITO-URINARY  Irregular heart beat  Hives Date of last  Blood in urine  Low blood pressure  Itching Pap Smear  Frequent urination  Poor circulation  Change in moles Have you had  Lack of bladder control  Rapid heart beat  Rash a mammogram?  Painful urination  Swelling of ankles  Scars Are you pregnant? Number of children  Varicose veins  Sores that won’t heal</p><p>MEDICAL HISTORY Check {} the medical conditions you have or have had in the past.  AIDS  Chemical dependency  Herpes  Polio  Alcoholism  Chicken Pox  High Cholesterol  Prostate Problem  Anemia  Diabetes  HIV Positive  Psychiatric Care  Anorexia  Emphysema  Kidney Disease  Rheumatic Fever  Appendicitis  Epilepsy  Liver Disease  Scarlet Fever  Arthritis  Gall Bladder Disease  Measles  Stroke  Asthma  Glaucoma  Migraine Headaches  Suicide Attempt  Bleeding Disorders  Goiter  Miscarriage  Thyroid Problems  Breast Lump  Gonorrhea  Mononucleosis  Tonsilitis  Bronchitis  Gout  Multiple Sclerosis  Tuberculosis  Bulimia  Heart Disease  Mumps  Typhoid Fever  Cancer  Hepatitis  Pacemaker  Ulcers  Cataracts  Hernia  Pneumonia  Vaginal Infections  Venereal Disease CONFIDENTIAL HEALTH HISTORY Work Form 5-1 (continued)</p><p>HOSPITALIZATIONS Year Hospital Reason for Hospitalization and Outcome</p><p>Have you ever had a blood transfusion?  Yes  No If yes, please give approximate dates: </p><p>OCCUPATIONAL CONCERNS HEALTH HABITS Check {} which PREGNANCY HISTORY Check {} if your work exposes you substances you use and indicate how much Year of Sex of Complications if any to the following: you use per day/week. Birth Birth  Stress  Caffeine  Hazardous Substances  Tobacco  Heavy Lifting  Drugs  Other  Alcohol</p><p>SERIOUS ILLNESS/INJURIES DATE OUTCOME</p><p>FAMILY HISTORY Fill in health information about your family. State of Age of Cause of Check {} if your blood relatives had any of the following Relation Age Health Death Death Disease Relationship to you Father  Arthritis, Gout Mother  Asthma, Hay Fever Brothers  Cancer  Chemical Dependency  Diabetes  Heart Disease, Strokes Sisters  High Blood Pressure  Kidney Disease  Tuberculosis  Other I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.</p><p>Signature Date</p><p>Reviewed By Date</p>