Medical History And Review Of Systems Form Page 2
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2HISTORY AND
REVIEW OF SYSTEMS
BACK
FAMILY HISTORY: Please check &/or list all family members that apply
Illness:
Relation to you (circle)
Alive
Deceased
Brain Aneurysm
Mother
Father
Sibling
Child
Other
o
o
Cancer
Mother
Father
Sibling
Child
Other
o
o
Diabetes
Mother
Father
Sibling
Child
Other
o
o
Heart Disease
Mother
Father
Sibling
Child
Other
o
o
Hypertension
Mother
Father
Sibling
Child
Other
o
o
Thyroid Problems
Mother
Father
Sibling
Child
Other
o
o
Stroke
Mother
Father
Sibling
Child
Other
o
o
SOCIAL HISTORY: Check &/or list all family members that apply:
Tobacco Use:
o Current / Former (Quit year ________) o Never o Exposure to smoke o E-cigs o Other: __________________
Alcohol Use:
o Never drink o Occasional drinker: _______ # drinks/day of alcohol
Drug Use:
o None o Other use: _____________________________________________________________________________
Caffeine Use:
o No o Yes – how much: __________________________________________________________________________
Marital Status:
o Married
o Divorced
o Widowed
o Single
Spouse’s Name: ________________________________________
# children ____________
# grandchildren ____________
REVIEW OF SYSTEMS: Check all that you are currently experiencing:
General History:
Ear/Nose/Throat:
Neurologic:
Vascular:
o Weight Gain
o Hoarseness
o Muscle Weakness
o Mini-Strokes/TIAs
o Weight Loss
o Choking
o Numbness
o Pain in legs when walking
o Increased Fatigue
o Sore Throat
o Seizures
o Cramping in legs
o Trouble Sleeping
o Ear Aches
o Memory Loss/Dementia
o Increased Appetite
o Sinus Drainage
Gastrointestinal:
Breast (Female):
Hematologic/Lymphatic:
o Heartburn
o Breast Mass
o Slow to Heal After Cuts
o Regurgitation
o Nipple Discharge:
o Easily Bruise or Bleed
o Difficulty Swallowing
If yes, what color? ________________
o Anemia
o Abdominal Pain
o Breast Pain/Tenderness
o Phlebitis
o Nausea
o Changes in Appearance
o Past Transfusion
o Vomiting
o Family History of Breast Cancer
o Enlarged Glands
o Bloating
OB/GYN (Female):
Allergic/Immunologic:
o Early Feeling of Fullness
o Date of Last Period ________________
o History of Skin Reaction To: ___________
o Rectal Bleeding
o Age of Menstruation ________________
o Penicillin or Other Antibiotics
o Constipation
o Menopause
o Morphine or Other Narcotics
o Diarrhea
o Novocaine or Other Anesthetics
Genitourinary:
o Change in Size/Color of stool
o Tetanus or Other Serums
o Difficulty Urinating
o # Bowel Movements/Day: ________
o Iodine or Other Antiseptic
o Urinating Frequently at Night
Respiratory:
o Known Food Allergies _______________
o Blood in Urine
o Difficulty Breathing
o Loss of Bladder Control
o Wheezing
o Weak Stream
o Cough:
o Mucous
o Blood
Endocrine:
Cardiac:
o Glandular or Hormone Problem
o Chest Pains
o Thyroid Disease
o Palpitations
o Excessive Thirst or Urination
o Swollen Feet
o Heat or Cold Intolerance
o Shortness of Breath (when lying flat)
o Cardiac Cath:
If yes, when: __________
o Cardiac Stress Test:
If yes, when: __________
NGMC FORM # 506040-02968 (6/18/15)
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