Providers Who Care MEDICAL HISTORY REVIEW OF SYSTEM FORM Date Name DATE OF BIRTH WIDOWED; OCCUPATION: No Of Children Tobacco UseYES/NO HOW MUCH? Day/Date Of Quit ALCOHOL USE: HOW MUCH PER DAY PAST ILLNESSES OF YOURSELF AND FAMILY: ALCOHOLISM You Your Family Both ANEMIA You Your Family Both ASTHMA You Your Family Both CANCER/TUMOR You Your Family Both DIABETES You Your Family Both DRUG ABUSE You Your Family Both DEPRESSION You Your Family Both EPILEPSY/SEIZURES You Your Family Both GLAUCOMA You Your Family Both HEART DISEASE You Your Family Both HIGH BLOOD PRESSURE You Your Family Both KIDNEY DISEASE You Your Family Both LIVER DISEASE You Your Family Both HEPATITIS You Your Family Both LUNG DISEASE You Your Family Both MENTAL ILLNESS You Your Family Both OSTEOARTHRITIS You Your Family Both OSTEOPOROSIS You Your Family Both PHLEBITIS You Your Family Both RHEUMATIC ARTHRITIS You Your Family Both STROKE You Your Family Both SUICIDE ATTEMPT You Your Family Both THYROID DISEASE You Your Family Both TUBERCULOSIS, TB You Your Family Both ULCER IN GI TRACT You Your Family Both VENEREAL DISEASE You Your Family Both HIGH CHOLESTEROL You Your Family Both HIV/IMMUNE DX You Your Family Both OTHER PAST SURGICAL HISTORY: PAST SURGICAL HISTORY: (PLEASE INCLUDE DATES) CONSTITUTIONAL Weight Loss Yes NO Fatigue Yes NO Fever Yes NO RESPIRATORY Cough Yes NO Coughing Blood Yes NO Wheezing Yes NO Chills Yes NO HEMATOLOGY/LYMPH Easy Bruising Yes NO Gums Bleed Easily Yes NO Easy Enlarged Glands Yes NO EYES: Glasses/Contacts Yes NO Eye Pain Yes NO Double Vision Yes NO Cataracts Yes NO MUSCULOSKELETAL: Joint Pain/Swelling Yes NO Stiffness Yes NO Muscle Pain Yes NO Back Pain Yes NO EAR,NOSE,THROAT: Difficulty Hearing Yes NO Ringing in Ears Yes NO Vertigo Yes NO Sinus Trouble Yes NO Nasal Stuffiness Yes NO GASTROINTESTINAL: Heartburn/Reflux Yes NO Nausea/Vomiting Yes NO Constipation Yes NO Change in BMs Yes NO Diarrhea Yes NO Jaundice Yes NO Abdominal Pain Yes NO Black or Bloody BM Yes NO CARDIOVASCULAR: Murmur Yes NO Chest Pain Yes NO Palpitations Yes NO Fainting Spells Yes NO Dizziness Yes NO Shortness of Breath Yes NO Difficulty lying Flat Yes NO Swelling Ankles Yes NO GENITOURINARY: Burning/Frequency Yes NO Nighttime Yes NO Blood in Urine Yes NO Erectile Dysfunction Yes NO Abnormal Discharge Yes NO Bladder Leakage Yes NO NEUROLOGICAL: Loss of Strength Yes NO Numbness Yes NO Headaches Yes NO Tremors Yes NO Memory Loss Yes NO SKIN: Rash/Sores Yes NO Lesions Yes NO Itching/Burning Yes NO ENDOCRINE: Heat/Cold Intolerance Yes NO Loss of Hair Yes NO PSYCHIATRIC: Anxiety/Depression Yes NO Mood Swings Yes NO Difficult Sleeping Yes NO ALLERGIC/IMMUNOLOGIC: Hives/Eczema Yes NO Hay Fever Yes NO FEMALES ONLY: Date Last Mammogram Normal OR Abnormal Date last PAP Normal OR Abnormal Age Onset Periods Age Onset Menopause Periods Regular? Yes NO Number Pregnancies NEW PATIENT- PLEASE COMPLETE THE FOLLOWING Name Date Yes/NoPREFERRED PHARMACY: LOCATION: NAMEPREVIOUS HEALTH CARE PROVIDERS IN PAST FIVE YEARS: NAME CITY/STATE PROBLEM CARED FOR: ALLERGIC AND ADVERSE REACTIONS TO MEDICATIONS NAME OF MEDICATION: ADVERSE REACTIONADDITIONAL INFORMATION: LAST MAMMOGRAM? WHERE? LAST PAP? GYN DR TO PERFORM FUTURE PAPS? Yes No LAST COLONOSCOPY? Normal DR REPEAT DATE? RECTAL EXAM? APPROXIMATE DATE OF LAST BLOODWORK? VACCINE DATES: TETANUS? FLU? PNEUMONIA? HEPATITIS B SERIES? Send
