Patient History Form (Page 2 of 4) in pdf

SYSTEMS REVIEW

As you review the following list, please check any of those problems, which have significantly affected you.

Date of last mammogram __________________ Date of last eye exam ________________ Date last chest x-ray ________________

Date of last Tuberculosis Test _________________ Date of last bone densitometry________________

Constitutional

Gastrointestinal

Integumentary (skin and/or breast)

 Recent weight gain

 Nausea

 Easy Bruising

amount________________

 Vomiting of blood or coffee ground material

 Redness

 Recent weight loss

 Stomach pain relieved by food or milk

 Rash

amount________________

 Jaundice

 Hives

 Fatigue

 Increasing constipation

 Sun sensitive (sun allergy)

 Weakness

 Persistent diarrhea

 Tightness

 Fever

 Blood in stools

 Nodules/bumps

Eyes

 Black stools

 Hair loss

 Pain

 Heartburn

 Color changes

of hands or feet in the cold

 Redness

Genitourinary

Neurological System

 Loss of vision

 Difficult urination

 Headaches

 Double or blurred vision

 Pain or burning on urination

 Dizziness

 Dryness

 Blood in urine

 Fainting

 Feels like something in eye

 Cloudy, “smoky” urine

 Muscle spasm

 Itching eyes

 Pus in urine

 Loss of consciousness

Ears-Nose-Mouth-Throat

 Discharge from penis/vagina

 Sensitivity

or pain of hands or feet

 Ringing in ears

 Getting up at night to pass urine

 Memory loss

 Loss of hearing

 Vaginal dryness

 Night sweats

 Nosebleeds

 Rash/ulcers

Psychiatric

 Loss of smell

 Sexual difficulties

 Excessive worries

 Dryness in nose

 Prostate trouble

 Anxiety

For Women only:

 Runny nose

 Easily losing temper

 Sore tongue

Age when periods began:_______________

 Depression

 Bleeding gums

Periods regular?  Yes  No

 Agitation

 Sores in mouth

How many days apart? ________________

 Difficulty falling asleep

 Loss of taste

Date of last period? _______________

 Difficulty staying asleep

 Dryness in mouth

Date of last pap? ________________

Endocrine

 Frequent sore throats

Bleeding after menopause?  Yes  No

 Excessive thirst

 Hoarseness

Number of pregnancies? _______________

Hematologic/Lymphatic

 Difficulty in swallowing

Number of miscarriages? _______________

 Swollen glands

Cardiovascular

Musculoskeletal

 Tender glands

 Pain in chest

 Morning stiffness

 Anemia

 Irregular heart beat

Lasting how long? ____________

 Bleeding tendency

 Sudden changes in heart beat

_______ Minutes ________ Hours

 Transfusion/when _________________

 High blood pressure

 Joint Pain

Allergic/Immunologic

 Heart murmurs

 Muscle Weakness

 Frequent sneezing

Respiratory

 Muscle tenderness

 Increased susceptibility to infection

 Shortness of breath

 Joint swelling

 Difficulty in breathing at night

List joints affected in the last 6 months

 Swollen legs or feet

_____________________________________

 Cough

_____________________________________

 Coughing of blood

_____________________________________

 Wheezing (asthma)

_____________________________________

Patient’s Name _____________________________________________ Date ___________________ Physician Initials __________

A-1520 (4/13)

Patient History Form Page 2

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