Health History Form (Page 2 of 2) in pdf

Current Medications: (include non-prescription medications and vitamins or supplements):

________________________________________________________________________________________________________________________

Other Doctors you see:

Specialty

________________________________________________________________________________________________________________________

Any additional information:

________________________________________________________________________________________________________________________

Review of Systems: (Check all symptoms you have had recently)

Constitutional

Gastrointestinal

Musculoskeletal

__ Nausea or vomiting

__ Muscle aches

__ Fever or chills

__ Loss of appetite

__ Constipation

__ Muscle weakness

__ Diarrhea

__ Backache

__ Weight change over 10 lbs

Eyes

__ Abdominal discomfort

__ Joint discomfort or stiffness

__ Bloating or excess gas

__ Wear glasses or contacts

Neurologic

__ Vision problem

__ Change in bowel habits

__ Headache

__ Eye discomfort or irritation

__ Change in stool size

__ Dizziness

__ Black bowel movements

__ Numbness or tingling

Ears, Nose, Mouth, Throat

__ Stuffy or runny nose

__ Rectal bleeding

__ Tremor or shaking

__ Hemorrhoids

__ Fainting or blackouts

__ Nosebleeds

__ Hearing loss

__ Difficulty swallowing

__ Difficulty walking

__ Heartburn

__ Sleep disturbance

__ Earache or ringing in ears

__ Sore throat

__ Intolerance of fatty foods

__ Seizures

__ Yellow skin or brown urine

__ Confusion or memory loss

__ Sores or lumps in mouth

__ Hoarseness of voice

Genitourinary

Psychiatric

Cardiovascular

__ Discomfort with urination

__ Sadness or depression

__ Chest discomfort

__ Excess urination

__ Anxiety or nervousness

__ Irregular or rapid heartbeat

__ Difficulty urinating

__ Suicidal or violent thoughts

__ Red or bloody urine

__ Hallucinations

__ Swelling of ankles or legs

__ Leg pain with walking

__ Lose urine accidentally

Hematologic Lymphatic

__ Vaginal discharge

__ Lymps in neck or under arms

Respiratory

__ Cough

__ Abnormal vaginal bleeding

__ Abnormal bleeding or bruising

__ Coughing up blood

__ Discharge from penis

Allergic/Immunologic

__ Shortness of breath

__ Testicle pain or swelling

__ Sneezing

__ Wheezing

__ Sexual problems

__ “Hay fever”

__ Hives

Integumentary

Endocrine

__ Moles or skin problems

__ Excessive thirst or urination

__ Intolerance of hot or cold

__ Breast lumps

__ Discharge from breast

__ Excessive perspiration

__ Abnormal lumps or growths

Date of your last menstrual period: _____________________________________

List below all other matters that you would like to be addressed:

________________________________________________________________________________________________________________________

Please Sign: ___________________________________________________________________ Date: ________________________

Updated 4/20/07

Health History Form Page 2

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