VA Gateway Urgent Care Center Medical History
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Today’s Date
Name
Age _______________ Birth Date _______________________
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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)
__________________________ _________________________ __________________________ ________________________
__________________________ _________________________ __________________________ ________________________
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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
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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.