Health History Intake Form - Cascade Internal Medicine Specialists Page 3
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4Past Medical History:
□ Yes
□ No
Head Aches
Date: ________________________
□ Yes
□ No
Stroke
_____________________________
□ Yes
□ No
Seizures
_____________________________
□ Yes
□ No
Pneumonia
_____________________________
□ Yes
□ No
Diabetes (Type 1 or Type 2)
_____________________________
□ Yes
□ No
Thyroid Disease (Low or High)
_____________________________
□ Yes
□ No
Glaucoma
_____________________________
□ Yes
□ No
Macular Degeneration
_____________________________
□ Yes
□ No
Hearing Loss
_____________________________
□ Yes
□ No
High Blood Pressure
_____________________________
□ Yes
□ No
Blood Clots
_____________________________
□ Pulm Emboli (lung clots)
□ Yes
□ No
_____________________________
□ DVT (leg clots)
□ Yes
□ No
_____________________________
□ Yes
□ No
Heart Burn, Reflux
_____________________________
□ Yes
□ No
Stomach Ulcers
_____________________________
□ Yes
□ No
Heart Disease
_____________________________
□ Coronary Disease
□ Yes
□ No
_____________________________
□ MI/heart attacks
□ Yes
□ No
_____________________________
□ Congestive Heart Failure
□ Yes
□ No
_____________________________
□ Atrial Fibrillation
□ Yes
□ No
_____________________________
□ Angina
□ Yes
□ No
_____________________________
□ Valve Disorder
□ Yes
□ No
_____________________________
□
□
High Cholesterol
Yes
No
__________________________
□
□
Gastrointestinal Bleeding
Yes
No
___________________________
□
□
Hepatitis (A, B, C)
Yes
No
_____________________________
□ Yes
□ No
HIV / AIDS
_____________________________
□ Yes
□ No
Chronic Wounds
_____________________________
□ Yes
□ No
Cancer (type)
_____________________________
□ Yes
□ No
Urinary Tract Infections
_____________________________
□ Yes
□ No
Incontinence
_____________________________
□ Yes
□ No
Kidney Stones
_____________________________
□ Yes
□ No
COPD (Emphysema, Bronchitis)
_____________________________
□ Yes
□ No
Asthma
_____________________________
□ Yes
□ No
Depression
_____________________________
□ Yes
□ No
Bipolar Disorder
_____________________________
□ Yes
□ No
Anxiety
_____________________________
□ Yes
□ No
Fibromyalgia
_____________________________
□ Yes
□ No
Chronic Fatigue Syndrome
_____________________________
□ Yes
□ No
Arthritis
_____________________________
□ Yes
□ No
Gout
_____________________________
□ Yes
□ No
Osteoporosis
_____________________________
□ Yes
□ No
Prostate Disease
_____________________________
□ Yes
□ No
Breast Disease
_____________________________
□ Yes
□ No
Erectile Dysfunction
_____________________________
Other_______________________________________________________________________________
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