Health History Intake Form - Cascade Internal Medicine Specialists Page 4

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Review of Systems
6 months
TODAY
(
Yes or No for symptoms in past
, circle for symptoms
)
Constitutional/Endocrine
Last pap smear:____________________________
□ Yes □ No
Fever
Results:__________________________________
□ Yes □ No
Total Pregnancies:__________________________
Chills
Total live births:___________________________
□ Yes □ No
Weakness/Fatigue
Total miscarriages:_________________________
□ Yes □ No
Weight Loss
Total abortions:___________________________
□ Yes □ No
Weight Gain
Total C-sections:__________________________
□ Yes □ No
Insomnia
□ Yes □ No
Snoring
Cardiac
□ Yes □ No
Excessive thirst
□ Yes □ No
Chest pain
□ Yes □ No
Excessive urination
□ Yes □ No
Palpitation
□ Yes □ No
Cold or Heat intolerance
□ Yes □ No
Irregular heartbeat
Other:____________________________
□ Yes □ No
Exercise intolerance
□ Yes □ No
Leg swelling
HEENT
Other:____________________________
□ Yes □ No
Sore Throat
□ Yes □ No
Stiff neck
Respiratory
□ Yes □ No
Change in your voice
□ Yes □ No
Persistent Cough
□ Yes □ No
Sinus Drainage
□ Yes □ No
Coughing up blood
□ Yes □ No
Sinus Head Ache
□ Yes □ No
Shortness of breath
□ Yes □ No
Nose Bleeds
□ Yes □ No
Wheezing
□ Yes □ No
Ear ache/drainage
Can’t breathe laying flat
□ Yes □ No
□ Yes □ No
Hearing Loss
Other:____________________________
□ Yes □ No
Ringing in your ears
□ Yes □ No
Blurred Vision/Loss
Skin
□ Yes □ No
Wear glasses or contacts
□ Yes □ No
Rashes/Hives
□ Yes □ No
Itchy/watery eyes
□ Yes □ No
Skin discoloration
□ Yes □ No
Dental problems
□ Yes □ No
Lesions/moles/warts
Other:____________________________
□ Yes □ No
Ulcers
□ Yes □ No
Itching
Gastrointestinal
□ Yes □ No
Nail Problems
□ Yes □ No
Nausea /Vomiting
□ Yes □ No
Unusual Hair loss
□ Yes □ No
Difficulty swallowing
□ Yes □ No
Easy bruising
□ Yes □ No
Hemorrhoids
Other:____________________________
□ Yes □ No
Diarrhea
□ Yes □ No
Constipation
Psych
□ Yes □ No
Bloody or Black Stools
□ Yes □ No
Depressed mood
□ Yes □ No
Abdominal pain
□ Yes □ No
Suicidal thoughts/plans
□ Yes □ No
Heart burn/indigestion
□ Yes □ No
Agitation/irritability
□ Yes □ No
Frequent use of Laxatives
□ Yes □ No
Insomnia
Other:____________________________
□ Yes □ No
Anxiety
□ Yes □ No
Frequent crying spells
Urinary
Other:____________________________
□ Yes □ No
Pain or burning with urination
□ Yes □ No
Urinary frequency (Night or Day)
Musculoskeletal
□ Yes □ No
Blood in urine / Dark urine
□ Yes □ No
Joint pains or stiffness
□ Yes □ No
Incontinence
□ Yes □ No
Joint swelling
□ Yes □ No
Slow starting or stopping urine
□ Yes □ No
Muscle weakness
Other:____________________________
□ Yes □ No
Back pain
□ Yes □ No
Muscle spasms/cramps
Genital/Sex Organs
□ Yes □ No
Falling
□ Yes □ No
Penile discharge
Other:____________________________
□ Yes □ No
Testicular lump/pain
□ Yes □ No
Breast Pain/discharge/lump
Neurologic
□ Yes □ No
Painful intercourse
□ Yes □ No
Frequent Headache
□ Yes □ No
Lack of sexual desire
□ Yes □ No
Seizures
□ Yes □ No
Problems with performance
□ Yes □ No
Syncope (passing out)
Other:____________________________
□ Yes □ No
Limb weakness
□ Yes □ No
Limb numbness
FEMALE Reproductive
□ Yes □ No
Dizziness
□ Yes □ No
Hot Flashes
□ Yes □ No
Swallowing difficulty
□ Yes □ No
Bleeding after menopause
□ Yes □ No
Balance issues
□ Yes □ No
Excessive menstrual bleeding
□ Yes □ No
Tremors
□ Yes □ No
Unusual vaginal discharge
□ Yes □ No
Rigidity
Age at onset of menstruation_____________________
Other:__________________________________________________
st
1
day of last menstruation_______________________
________________________________________________________
□ Yes □ No
Menstrual pain/cramps
________________________________________________________
□ Yes □ No
Spotting between periods
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