New Patient History Form (Page 4 of 7) in pdf

NEW PATIENT MEDICAL HISTORY FORM

______________________

Patient Name: ___________________________________________________ MRN#

Review of Symptoms: (Please check any current symptoms you have.)

General:

Weight loss

How much__________________

Over what time period_________

GASTROINTESTINAL:

Fevers

Difficult or painful swallowing

SKIN:

Max temp__________

Abdominal pain

Chills

Nausea

Rashes or itching

Night sweats

Vomiting

Change in skin color or moles

Fatigue

Heartburn

Varicose veins

Indigestion

Skin Cancer

EYES:

Lump or sensation in throat

PSYCHIATRIC:

Wear Glasses/Contact Lenses

Food sticking

Blurred Vision

Bloating

Anxiety/Agitation

Double Vision

Belching

Depression

Diarrhea

Crying for no reason

Ears, Nose, Throat:

Constipation

Insomnia

Hard of hearing or deaf

Rectal bleeding

Alcoholism

Ringing in Ears

Black or tarry stools

Drug Problem (Now/Past)

Enlarged lymph nodes

Hidden blood in stool

Chronic sinus Problems

Excessive rectal gas/flatus

HEMATOLOGIC:

Sore throat

Loss of stool/fecal accident

Easy bruising

Mouth pain/sores

Poor appetite

Gum or nose bleeding

Jaundice

Blood transfusion in past

CHANGES/DIFFICULTY IN:

GENITOURINARY:

Taste

Allergies/Immunology:

Smell

Kidney Stones

History of chronic infections

Voice

Pelvic Pain

History of allergies

Incontinence

CARDIOVASCULAR:

Burning or pain on urination

ENDOCRINE:

Chest pain/Angina Pectoris

Blood in Urine

Heat or cold intolerance

Palpitations/heart murmur

Difficult urination

Excessive Skin Dryness

Irregular heart beat Pressure

Men: Prostate problems

Excessive thirst or urination

Weight problem

RESPIRATORY:

MUSCULOSKELATAL:

Hot flashes

Chronic or Frequent Cough

Joint Pain/Arthritis

Bloody Sputum

Muscle or joint weakness

BREAST:

Shortness of Breath

Back Pain

Rashes or itching

Bone Pain

Change in skin color or moles

Muscle aches

Varicose veins

Skin Cancer

NEUROLOGICAL:

Numbness, tingling

Gynecology:

Arm or leg weakness

Age at start of menses_______

Light-Headed, dizzy, fainting

Last menstrual period________

spells

Breast pain/lump

Headache

Breast discharge or rash

Tremors

Vaginal discharge

Menstrual irregularity or

abnormal bleeding

____________

Patient’s Initials

New Patient History Form Page 4

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