Medical History Form (Page 4 of 4) in pdf

Medical History Form Page 4

NAME:____________________________________

TO BE COMPLETED BY PHYSICIAN

APPOINTMENT DATE:______________________

TO BE COMPLETED BY PATIENT

Physical Exam (continued):

For children under 15, complete the following:

CVS: Heart-

1. Birth Weight:____________________________

PV (observ/palp)-

2. Were there any complications following delivery?

[ ] Yes

[ ] No

ABDOMEN:

Tenderness

Mass

Explain:

Liver/Spleen – Normal

Enlarged

3. Has growth and development been normal?

[ ] Yes

[ ] No

EXTREMITIES:

Explain:

4. Are immunizations up to date?

SKIN:

Normal

Lichenified

Excoriated

[ ] Yes

[ ] No

Oozing

Erythema

Wheals

Papules

Dermatographic

Social History:

Current Occupation:_______________________________

Mother’s Occupation:______________

(if applicable):

Father’s Occupation:_______________

Marital Status:

NEURO/PSYCH:

Orientation -

[ ]Single [ ]Married [ ]Divorced [ ]Widowed

Mood/Affect -

[ ]Significant Other [ ]Life Partner

OTHER:

Smoking History:

[ ]Current [ ]Past Started/How long_____________

NOTES:

Environmental History: (

Please check the appropriate boxes)

Home: [ ]House [ ]Apartment [ ]Condo

[ ]Mobile Home

Age of Home___________

Pets: [ ]Cat

[ ]Indoor [ ]Outdoor

[ ]Dog [ ]Indoor

[ ]Outdoor

[ ]Other [ ]Indoor

[ ]Outdoor

Smokers in the home:

[ ]None

[ ]Indoors by __________ [ ]Outdoors by___________

Heat: [ ]Central

[ ]Radiator

Air conditioning:

[ ]Central

[ ]Window

Pillows:

[ ]Feather

[ ]Non-feather

Age:______

Bed:

[ ]Mattress/Boxspring

[ ]Waterbed

[ ]Bunkbed

Top Bunk____ Bottom Bunk____

Age:____________

Flooring:

[ ]Hardwood [ ]Carpet

Age:_________

Basement or Crawlspace:

[ ]Dry

[ ]Damp

[ ]Musty

Birmingham Allergy & Asthma Specialists, PC

Medical History Form Page 4

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