Drug Allergy/drug Side Effects Or Ineffectiveness Chart
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1
2Name: _____________________________________________________
Date of Birth: __________________
Today’s date: _________________
Drug Allergy / Drug Side Effects or Ineffectiveness
Indicate any true drug allergy you have had (rash, swelling, itching, breathing problem): ___________________________________________________
___________________________________________________________________________________________________________________________
List any drug(s) that have caused unpleasant side effects (nausea, diarrhea, dry mouth, excessive drowsiness, etc) or have not worked well for you:
Personal and Family Medical History
1. Place an “X” in the box that indicates any of the listed medical conditions that apply to you or a listed family member
2. ***IMPORTANT: List the age at which you were diagnosed with any of the listed conditions in the same column you place the “X”
3. Code or legend for the family members: M=mother;
F=Father;
Br=brother;
Sis=sister;
Daug=daughter
MGM=maternal grandmother
MGF=maternal grandfather;
PGM= paternal grandmother;
PGF=paternal grandfather
Yourself & Age
I was adopted and do not have details of family history
M
F
Sis
Br
Daug
Son
MGF
PGM
PGF
MGM
Diagnosed
High blood pressure
My age ___
High cholesterol and/or triglycerides
My age ___
Heart disease: __heart attack __ bypass
__ stent
__angioplasty
My age ___
Heart: __heart failure
__irregular heart beats
__blood clot
My age ___
Diabetes:
Insulin use: No__ Yes__
My age ___
Intestinal: __Acid reflux
__peptic ulcer
__intestinal bleed
My age ___
Intestinal: __Colon polyp
__diverticulitis
__spastic colon
My age ___
Lung: __asthma __emphysema / chronic bronchitis
__sleep apnea
My age ___
Thyroid disease: __under-active
__ overactive
__ both
My age ___
Cancer - List type(s): ___________________________
My age ___
Arthritis: __common arthritis __ rheumatoid arthritis
__unknown
My age ___
Kidneys:
__ loss of bladder control
__ kidney stones
My age ___
__bladder infections
__prostate infections
__ enlarged prostate
My age ___
Nervous System: __seizures
__ neuropathy
__Parkinsons disease
My age ___
Stroke: __complete stroke
__mini-stroke (TIA)
My age ___
Headaches:
__tension
__ migraine
__ cluster
__unknown
My age ___
Mental: __ depression __anxiety
__bipolar
__schizophrenia
My age ___
Chemical dependency: __ alcoholism
__other drugs __________
My age ___
Blood: __anemia(type if known____________) __ bleeding tendency
My age ___
Eye: __Glaucoma __cataracts __ macular degeneration __blindness
My age ___
Adult Females
Adult Males
1) If over age 40, have you had a mammogram within a year?
Yes
No
1) If over 50, have you had a PSA within a year?
Yes
No
2) If over 50, have you had a colon cancer screening
2) Have you had a PAP smear/pelvic exam within a year?
Yes
No
within the past year?
Yes
No
3) If over 50, have you had a colon cancer screen within a year?
Yes
No
List the year of your last vaccination:
Tetanus: Date_____
Unknown
Flu Vaccine: Date_______
Unknown
Pneumonia Vaccine: Date_______
Unknown
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