Va Gateway Urgent Care Center Medical History

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VA Gateway Urgent Care Center Medical History
_____________
Today’s Date
Name
Age _______________ Birth Date _______________________
__________________________________________
Sex
 Male  Female
Address
__________________________________________
Home Phone ________________________________________
__________________________________________
Work Phone _________________________________________
__________________________________________
Emergency Contact ___________________________________
Occupation
__________________________________________
Phone ______________________________________________
 Single
 Married
 Divorced
 Widowed
 Separated
If married, spouse’s name ____________________________________________________________________________________
Children’s names and ages ____________________________________________________________________________________
Allergies to Medications, X-Ray Dyes, or Other Substances
 No
 Yes
(If yes, please list name of medicine and type of reaction)
__________________________ _________________________ __________________________ ________________________
__________________________ _________________________ __________________________ ________________________
__________________________ _________________________ __________________________ ________________________
__________________________ _________________________ __________________________ ________________________
Past Medical History and Review of Systems
Please check off if you have had any problems with or are presently experiencing any of the following:
 High Blood Pressure
 Bronchitis
 Change in bowel habits
 Arthritis
 Diabetes
 Pneumonia
 Unexplained weight
 Low back problems
 Cancer
 Persistent cough
 Skin diseases
gain/loss
 Heart Disease
 T.B.
 Hemorrhoids
 Blood disorders
 Chest pain/chest tightness
 Hay fever
 Gall Bladder disease
 Venereal diseases or STDS
 Shortness of breath
 Abdominal discomfort
 Colitis
 Anxiety
 Swollen ankles
 Indigestion
 Hepatitis or jaundice
 Depression
 Palpitations
 Nausea
 Thyroid disease
 Anemia
 Lightheadedness
 Vomiting
 Head or neck radiation
 Alcohol abuse
 Frequent urination
 Constipation
 Headache
 Drug abuse
 Rheumatic fever
 Diarrhea
 Kidney disease
 Gout
 Asthma
 Blood in stool
 Kidney stones
 Impotence or
 History of blood transfusion
 Ulcers
 Difficulty urinating
Erectile Dysfunction
 Other
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Gynecologic and Obstetric History
Age at onset of periods ________________ Frequency __________________________ Length of period _____________________
Pregnancies ________________________ Births _____________________________ Miscarriages _________________________
Prolonged or abnormal bleeding
 No  Yes (Please describe) ______________________________________________
Leakage of urine
 No  Yes (Please describe) ______________________________________________
Pelvic pain
 No  Yes (Please describe) ______________________________________________
Abnormal discharge
 No  Yes (Please describe) ______________________________________________
History of abnormal Pap smear
 No  Yes (Please describe) ______________________________________________
This information is for use by your physician as part of your confidential medical record.

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