Patient History Information Form Page 3
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4Social History:
Substance Use:
Do you smoke cigarettes?
YES
NO
AMOUNT:
Do you drink alcohol?
YES
NO
AMOUNT:
Do you consume caffeine?
YES
NO
AMOUNT:
Do you use any recreational drugs?
YES
NO
TYPE/AMOUNT:
Exercise:
How often do you exercise per week? ______________________________________________________________________
What types of exercise do you prefer? ______________________________________________________________________
Safety:
Do you feel safe at home? ________________________________________________________________________________
Do you feel safe in ALL of your current relationships? ___________________________________________________________
______________________________________________________________________________________________________
Review of Systems
Please complete this form for each visit to your care provider. Please circle ANY symptom that you are currently experiencing or
have experienced in the last ONE YEAR. Give details whenever possible.
Constitutional
Fatigue
Fever
Chills
Body Aches
Night Sweats
Weight Gain
Weight Loss
Loss of Appetite
Eyes
Discharge from Eye
Eye Discomfort
Impaired Vision
Head-Ears-Nose-Throat
Headaches
Lightheadedness/ Fainting
Recent Head Injury
Nasal Congestion
Nose Bleeding
Nasal Discharge
Decreased Hearing
Sinus Pain
Sore Throat
Dental Problems
Ringing in Ears
Breasts
Lumps
Tenderness
Dimpling
Abnormal Changes in Breast Size
Redness
Nipple Discharge
Swelling
Cardiovascular
Chest Pain
Irregular Heart Beats
Rapid Heart Rate
Leg/ Ankle/ Foot Swelling
Varicosities
Respiratory
Shortness of Breath
Wheezing
Tuberculosis Exposure
Cough
Hoarseness
Gastrointestinal
Nausea
Hemorrhoids
Abdominal Pain
Diarrhea
Constipation
Vomiting
Bloating
Change in Stools
Heartburn
Jaundice
Genitourinary
Urinary Urgency
Difficulty Urinating
Absence of Menstrual Period
Pain with Periods
Urinary Frequency
Pain with Urination
Irregular Menstrual Periods
Significant PMS Symptoms
Blood in Urine
Pain with Intercourse
Heavy Bleeding with Periods
Genital Sores
Leakage of Urine
Abnormal Vaginal Discharge
Bleeding After Intercourse
Decreased Sex Drive
(OVER)
4/11
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