Form Rfmc 212 - Patient Health History Form printable pdf download

WESTERN WISCONSIN MEDICAL ASSOCIATES

River Falls – Ellsworth – Spring Valley

PATIENT HEALTH HISTORY

DATE

COMPLETED

NAME

AGE

DOB

OCCUPATION

SIGNIFICANT OTHER

LIST ALL SPECIALIST AND PROVIDERS OF HEALTH CARE OUTSIDE OF OUR CLINIC (I.E. CARDIOLOGIST, NEUROLOGIST, UROLOGIST,

PHARMACY, EYE DOCTOR, DENTIST, DIABETIC SUPPLIER ETC.)

I currently have Advanced Directives on ﬁ le:

Yes

I would like information about Advanced Directives:

Yes

Please indicate if you have had any of the following in the past 3 months:

SYSTEM REVIEW:

General

YES NO

Cardiovascular

YES NO

Hematologic

YES NO

Anemia

Weight Loss

Chest Pain

Easy Bruising

Weight Gain

Heart Fluttering

Easy Bleeding

Fever

Difﬁ culty Lying Flat

Prior Blood Transfusion

Chills

High Blood Pressure

Swollen Lymph Nodes

Fatigue

Swelling In Legs

Loss Of Consciousness

Endocrine

YES NO

Eyes

YES NO

Fainting

Intolerance To Heat

Wear Glasses

Intolerance To Cold

Wear Contacts

Gastrointestinal

YES NO

Excessive Hunger

Vision Change

Nausea

Excessive Thirst

Last Eye Exam __________________

Vomiting

Eye Pain

Allergic / Immunologic

YES NO

Diarrhea

Seasonal Allergies

Double Vision

Heartburn

Recurrent Infections

Blood In Stools

Chicken Pox Disease

Ears, Nose, Throat, Mouth

YES NO

Black/tarry Stool

Chicken Pox Vaccine

Ringing in Ears

Constipation

Last Tetanus Booster _____________

Decreased Hearing

Ulcer Disease

Last Pneumonia Vaccine ___________

Ear Pain

Runny Nose

Urologic / Gynecologic

YES NO

Musculoskeletal

YES NO

Sneezing

Pain With Urination

Joint Pain

Sinus Infections

Frequent Urination

Back Pain

Nose Bleeds

Increased Urge To Urinate

Muscle Pain

Sore Throat

Difﬁ culty Urinating

Recent Injuries / Falls

Last Dental Exam ________________

Up At Night Urinating

Skin

YES NO

Voice Change

Losing Urine Control

Changing Moles

Sexually Transmitted Diseases

Skin Cancer

Respiratory

YES NO

Males:

Cough

Difﬁ culty With Erection

Neurologic

YES NO

Short Of Breath

Females:

Headaches

Wheezing

Age Of First Menses ___________

Numbness / Tingling

Asthma

Regular Menses

Memory Changes

Heavy Snoring/Sleep Apnea

Menstrual Duration ________ Days

Cycle Interval ____________ Days

Social / Family

YES NO

Last Menses Started ___________

History Of Abuse

Abnormal Pap Smear

CONTINUES ON REVERSE

RFMC 212

Rev. 05/11

(Rev. 9/2014)

VHFC–PA 86891

Form Rfmc 212 - Patient Health History Form

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