Medical & Family History Form Page 2
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1
2MEDICAL & FAMILY HISTORY FORM
□ Father
□ Mother
□ Brothers
□ Sisters
Healthy/Alive
□ Father
□ Mother
□ Brothers
□ Sisters
Deceased
□ Father
□ Mother
□ Brothers
□ Sisters
Colon polyps
□ Father
□ Mother
□ Brothers
□ Sisters
Colon cancer
Gastriculcer disease
□ Father
□ Mother
□ Brothers
□ Sisters
□ Father
□ Mother
□ Brothers
□ Sisters
Liver disease
□ Father
□ Mother
□ Brothers
□ Sisters
Pancreas disease
□ Father
□ Mother
□ Brothers
□ Sisters
Crohn's disease
Ulcerative colitis
□ Father
□ Mother
□ Brothers
□ Sisters
Stomach cancer
□ Father
□ Mother
□ Brothers
□ Sisters
Diabetes mellitus
□ Father
□ Mother
□ Brothers
□ Sisters
Heart attack
□ Father
□ Mother
□ Brothers
□ Sisters
Breast cancer
□ Father
□ Mother
□ Brothers
□ Sisters
Other cancer
□ Father
□ Mother
□ Brothers
□ Sisters
Social History
Marital status: □ single □ married □ divorced □ widowed □ separated □ domestic partner
Occupation:___________________□ unemployed □ retired □ student
Smoking history: □ never □ yes;__________packs per day for _________years; Quit (how long)___________________________
Alcohol use: □ no □ yes; amount per day:_________________for____________________years
Drug use: □ no □ yes; specify drugs and amounts: _________________________________________________________________
Exercise habits: □ no □ yes; how much and how often: _____________________________________________________________
Do you have any tattoos?
□ no
□ yes
Do you have any piercings?
□ no
□ yes
Recent travel outside US: □ no
□ yes; where:__________________________________________________________________
Caffeine use: □ no □ yes; details:______________________________________________________________________________
Date of last Pneumovax: ______________________________Date of last flu shot:_____________________________________
Review of Systems—check all that apply at the present time
General-
Pulmonary-
Musculoskeletal-
Endocrine-
□ chills
□ cough
□ joint pain
□ heat or cold intolerance
□ fever
□ wheezing
□ joint stiffness
□ excessive thirst or urination
□ loss of appetite
□ shortness of breath
□ swollen joints
□ hot flashes
□ night sweats
Gastrointestinal-
□ low back pain
Hematologic/Lymphatic-
□ weight gain
□ abdominal swelling/pain
□ muscle pain
□ easy bruising tendency
□ weight loss
□ belching
Skin Symptoms-
□ swollen glands
□ feeling tired or poorly
□ black stools
□ Pruritis (itching)
□ nosebleeds
Eyes-
□ red blood in bowel movement
□ skin lesions
Urinary-
□ worsening of vision
□ change in bowel movement frequency
□ rashes
□ pain or difficulty with urination
□ blurred vision
□ constipation
Neurologic-
□ frequent urination
□ vision distortion
□ diarrhea
□ numbness or tingling
□ blood in urine
□ eye pain
□ difficulty swallowing
□ dizziness/lightheadedness
□ incontinence of urine
Otolaryngeal Systems-
□ fatty food intolerance
□ vertigo
Genitoreproductive-Female
□ earache
□ full after eating small meals
□ headaches
□ vaginal discharge
□ nasal discharge
□ gas/bloating
□ weakness in arms or legs
□ heavy periods
□ mouth sores
□ heartburn
□ blurred vision
date of last period:__________
□ bleeding gums
□ hemorrhoids
□ memory lapses or loss
Genitoreproductive-Male
□ hoarseness
□ yellow skin or eyes
Psychiatric-
□ discharge from penis
□ throat pain
□ nausea
□ anxiety
□ testicular pain
□ facial pain
□ pain with swallowing
□ testicular lump
□ depression
□ sinus pain
□ decrease in appetite
□ panic attacks
Cardiovascular-
□ rectal pain/bleed
□ loss of sleep
□ chest pain/discomfort
□ regurgitation of food
□ fast heart rate
□ incontinence of stool
□ swelling of legs
□ vomiting
Page 2
□ varicose veins
□ vomiting blood
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Parent category: Medical