Online Patient History Form

CHIEF COMPLAINT





 



 




MEDICAL HISTORY

Check all of your prior or current illnesses or conditions.
Asthma
 
Cancer
 
Emphysema
 
Hepatitis
 
Impotence
 
Lung
 
Pregnancy
 
Stroke
 
Asthma
 
Diabetes
 
Heart Attack
 
High Blood Pressure
 
Kidney
 
Osteoarthritis
 
Rheumatoid Arthritis
 
Thyroid
 
Blood clots
 
Emotional Stress
 
Heart Disease
 
HIV/AIDS
 
Liver Disease
 
Osteoporosis
 
Seizure
 
Tuberculosis
 

 

REVIEW OF SYMPTOMS

Check all that you have or have had in the past. CONSTITUTIONAL
fever
weight loss
night sweats
"feel sick"
 
EYES
Vision Changes
EARS/NOSE/THROAT
hearing loss
sinus
CARDIOVASCULAR
chest pain
irregular heartbeat
RESPIRATORY
shortness of breath
persistent cough
GASTROINTESTINAL
diarrhea
constipation
abdominal pain
dark stools
heartburn
MUSCULOSKELETAL
joint pain
stiffness
swelling
SKIN
normal
acne
bites (insect)
bruising
bumps
nail problems
hair problems
itching
lumps
mole changes
nail problems
other lesions
rash
scars
sweating
wounds
NEUROLOGICAL
poor balance
coordination
memory
seizures
falls
EMOTIONAL
depression
anxiety
hallucinations
moodiness
ENDOCRINE
excessive thirst
low energy
high energy
HEMATOLOGICAL
bleeding tendency
swollen nodes
anemia
ALL SYSTEM
normal
abnormal
 


MEDICATION LIST


 

MEDICATION ALLERGIES


No known drug allergies
No known food, contact or environmental allergies

Allergic to: Penicillin Codeine Sulfa

Have you ever had reaction to local anesthesia:

 


FAMILY HISTORY

Check all that apply if a close relative has/had any of these problems.
High blood pressure
 
Stroke
 
Arthritis
 
Skin Cancer
 
Diabetes
 
Heart attack
 
Back problems
 
Osteoporosis
 
Mental illness
 
Scoliosis
 

 

SOCIAL HISTORY

Select the answer that applies.

 

 

 

 

SURGICAL HISTORY

List surgeries or hospitalization(s) within the past 10 years. Include approximate date and surgeon




 




 



 
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