North Shore Lij Medical History Form Page 3
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1
2
3Have you recently experienced any of the following (circle what applies, or circle NEGATIVE):
GENERAL:
Negative
FATIGUE
FEVER
WEIGHT CHANGE
SWEATS
CHILLS
WEAKNESS
EYES:
Negative
VISION CHANGES
INTOLERANCE TO LIGHT
BLURRY VISION
EYE PAIN
ENT:
Negative
EAR PAIN
RINGING IN THE EARS
SORE THROAT
NOSE BLEEDS
DIFFICULTY SWALLOWING
CARDIOVASCULAR:
Negative
CHEST PAIN
SYNCOPE
PALPITATIONS
SHORTNESS OF BREATH
RESPIRATORY:
Negative
COUGH
WHEEZING
COUGHING UP BLOOD
SPUTUM PRODUCTION
GASTROINTESTINAL:
Negative
ABDOMINAL PAIN
NAUSEA
VOMITING
DIARRHEA
BLOOD IN STOOL
MUSCULOSKELETAL:
Negative
JOINT PAIN
WEAKNESS
JOINT SWELLING MUSCLE PAIN
SKIN:
Negative
RASHES
HIVES
ITCHY SKIN
MASSES
BREAST PAIN
NEUROLOGICAL:
Negative
HEADACHES
DIZZINESS
SEIZURES
MOTOR CHANGES
HEMATOLOGIC:
Negative
ABNORMAL BLEEDING
ABNORMAL BRUISING
PSYCHIATRIC:
Negative
ANXIETY
DEPRESSSION
MANIA
SUICIDAL THOUGHTS
PHOBIAS
REFERRING INFORMATION
To provide you the best care, please complete the following information to allow us to send reports to your doctors.
Referring Physician
Name:
Address:
Phone #:
Fax#:
Primary Care Physician
Name:
Address:
Phone #:
Fax#:
Additional Physician
Name:
Address:
Phone #:
Fax#:
Reviewer Signature
Date reviewed
Last Name _____________________________ 3/3
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Parent category: Medical