Michigan Spine And Brain Surgeons Form Page 2

ADVERTISEMENT

MICHIGAN SPINE AND BRAIN SURGEONS PLLC
REVIEW OF SYSTEMS, do you have:
Constitutional:
recent weight loss
low energy level
fever
loss of appetite
Eyes:
blurring of vision
flying black spots
loss of visual fields
double vision
ENT:
nasal discharge
nose bleeding
Ringing in the ears
Trouble hearing
Trouble swallowing
Cardiovascular:
loss of consciousness
Palpitation
short of breath
Angina
Pedal edema
Respiratory:
short of breath
cough
sputum
wheezing
Gastrointestinal:
nausea/vomiting
reflux
ulcer
bloody diarrhea
constipation
jaundice
Genitourinary:
painful urination
hesitancy
poor stream
failure to eject
failure to erect
Reproductive:
Normal
abnormal
Sexual function:
Normal
abnormal
Musculoskeletal:
neck pain
Arm pain/weakness/numbness
Back pain
Leg pain/weakness/numbness
Skin/Breast:
rash
skin peeling
breast enlargement
milk from the nipple
Neurological:
headaches
Dizziness
seizure
vertigo
Trouble speaking
in coordination
Psychiatric:
depression
anxiety
Trouble sleeping
Memory loss
Endocrine:
frequent urination
frequent thirst
cold/heat intolerance
tremors
recent gain in weight
Hematology:
Anemia
easy bruising
leukemia
lymphoma
Allergic/Immunologic:
post-nasal drip
facial rash
frequent infections
diffuse joint swellings
PAST MEDICAL HISTORY:
Medical Illnesses
Operations (type and date)
1. Ischemic heart disease
4.
1.
4.
yes
No
2. Diabetes
5.
2.
5.
yes
No
3. High blood pressure
6.
3.
6.
yes
No
Current Medications (dose, route and frequency)
Trauma (type and date)
Allergies
1.
5.
1.
1.
Reaction:
2.
6.
2.
2.
Reaction:
3.
7.
3.
3.
Reaction:
4.
8.
4.
4.
Reaction:
FAMILY HISTORY:
Negative
Ischemic heart disease
Diabetes
Bleeding tendency Other:______________
Father: What age_____________
Living
Deceased
Cause of Death_______________________________
Mother: What age_____________
Living
Deceased
Cause of Death_______________________________
SOCIAL HISTORY:
married
divorced
widowed
children #____
single
living with_______
Work status:
part-time
full time
sick leave
disabled, last day worked ______
unemployed
retired
Litigation:
active
Yes
No
settled
Yes
No
Tobacco:
Never
Presently use________# cigarettes/day
Quit since___________________________
Alcohol:
Never
Occasional
Frequent, quantify_________________________________
Weight_________ Height_________ BMI________ BP________
Right-handed
Left-handed
_________________________________________________________
______________________________
Patient Signature (Parent or Guardian if patient is a minor)
Date
Person Obtaining HP __________
Version 02/23/2014

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Michigan State University Direct Deposit Form Michigan State University Direct Deposit Form Financial
Michigan Vehicle Dealer Closeout Statement Form Michigan Vehicle Dealer Closeout Statement Form Legal
Michigan Sales And Use Tax Contractor Eligibility Statement Form For Qualified Nonprofit Hospitals, Nonprofit Housing, Church Sanctuaries, And Pollution Control Facilities Exemptions Michigan Sales And Use Tax Contractor Eligibility Statement Form For Qualified Nonprofit Hospitals, Nonprofit Housing, Church Sanctuaries, And Pollution Control Facilities Exemptions Financial
Michigan Sales, Use, And Withholding Tax Forms And Instructions Michigan Sales, Use, And Withholding Tax Forms And Instructions Financial
Form Rd 108 - Application For Michigan Title And Registration Statement Of Vehicle Sale Form Rd 108 - Application For Michigan Title And Registration Statement Of Vehicle Sale Legal
Michigan Sales And Use Tax Certificate Of Exemption - City Of Flint Michigan Sales And Use Tax Certificate Of Exemption - City Of Flint Financial
Form 3372 - Michigan Sales And Use Tax Certificate Of Exemption Form 3372 - Michigan Sales And Use Tax Certificate Of Exemption Financial
Form 3165 - Michigan Holder Request For Refund Form - Michigan Department Of Treasury Form 3165 - Michigan Holder Request For Refund Form - Michigan Department Of Treasury Financial
Michigan Sales And Use Tax Certificate Of Exemption Form Michigan Sales And Use Tax Certificate Of Exemption Form Financial
Form 3372 - Michigan Sales And Use Tax Certificate Of Exemption - 2005 Form 3372 - Michigan Sales And Use Tax Certificate Of Exemption - 2005 Financial

Related Categories

Parent category: Medical
Download
Go
Page of 2