Medicine Complete Physical Exam Form Page 4
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4MEDICINE COMPLETE PHYSICAL EXAM
REVIEW OF SYSTEM
Yes
No
Comments
Do you have any bleeding or bruising ten-
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dency?
Anemia or low blood count?
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Phlebitis or blood clot?
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Past blood transfusion?
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Enlarged glands?
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ALLERGIC/IMMUNOLOGIC
Yes
No
Do you have any history of skin reaction or
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other adverse reaction to:
Penicillin or or antibiotics?
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Morphine, Demerol or other narcotics?
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Novocaine or other anesthetics?
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Aspirin or other pain remedies?
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Tetanus vaccines or other serums/
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vaccines?
Iodine, methiolate or other antiseptics?
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Other drugs/medications?
Please list: __________________________________
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Food allergies?
Please list: __________________________________
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SOCIAL HISTORY
Yes
No
Do you use tobacco?
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Do you use alcohol?
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Do you use drugs?
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Do you work?
Occupation:_________________________________
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FAMILY HISTORY
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No
Relatives (current age or age at death)
Alive
Died
Cause of death/Disease
Father: age ______
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Mother: age ______
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List brothers/sisters with age
List any disease or cause of death
Alive
Died
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BERGEN KIDNEY CENTER, P.C.
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