Medical History And Review Of Systems Form
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1
2HISTORY AND
REVIEW OF SYSTEMS
FRONT
Name: _____________________________________________________ DOB: _____ / _____ / _____ Today’s Date: _________________
Primary Care Physician: _______________________________________ Referring Physician: ___________________________________
What are we seeing you for today? ___________________________________________________________________________________
How long have you had this problem? ____________________ Telephone or location of your pharmacy: ___________________________
CURRENT MEDICAL HISTORY: Please check (3) all that apply:
o Abnormal Heart Rhythm
o COPD
o Heart Attack
o Pneumonia
o Anemia
o Colon Polyps
o Hiatal Hernia/GERD
o Stomach Ulcers
o Aneurysm
o Congestive Heart Failure
o High Cholesterol
o Stroke
o Arthritis
o Coronary Artery Disease
o High/Low Blood Pressure
o TIA
o Asthma
o Depression
o Implanted Device
o Thyroid Disease
o Cancer:
_____________
o Diabetes: o Type I o Type II
o Kidney Disease/Stones
o Tuberculosis
type
o Carotid Artery Disease
o Emphysema
o Liver Disease
o Ulcers
o Cirrhosis of the Liver
o Epilepsy
o Low Blood Sugar
ALLERGIES: List all medication and/or food allergies and the type of reaction (Ex: Sulfa-rash, Codeine-nausea, etc.)
Allergy:
Type of reaction:
1. ______________________________________________________
_____________________________________________________
2. ______________________________________________________
_____________________________________________________
3. ______________________________________________________
_____________________________________________________
4. ______________________________________________________
_____________________________________________________
5. ______________________________________________________
_____________________________________________________
Are you allergic to latex? o Yes o No
Circle any of the following that you are currently taking on a regular basis:
Aspirin
Arthritis medication
Xarelto
Eloquis
Coumadin/Warfarin
Other blood thinner
CURRENT MEDICATIONS: List all medications:
Over-the-Counter
Medicine
Dosage
How Often?
Provider
Vitamins and Supplements
EX: Lasix
20 mg
Twice a day
Dr. Jones
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
SURGICAL HISTORY:
Appendectomy – Date: __________________________________
Endoscopy – Date: _____________________________________
Back/Neck – Date: _____________________________________
Gallbladder – Date: _____________________________________
Bariatric – Date: _______________________________________
Hernia Repair – Date: ___________________________________
Breast – Date: _________________________________________
Hysterectomy – Date: ___________________________________
Cardiac – Date: ________________________________________
Reflux – Date: _________________________________________
Colon – Date: _________________________________________
Thyroid – Date: ________________________________________
Colonoscopy – Date: ___________________________________
Other abdominal surgery: – Date: _________________________
NGMC FORM # 506040-02968 (6/18/15)
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