Medical History Review Of System Form
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1
2MEDICAL HISTORY
REVIEW OF SYSTEM FORM
DATE:________________NAME:_________________________________________DATE OF BIRTH___________
____MARRIED ____SINGLE ____DIVORCED ____WIDOWED; OCCUPATION:___________________________
NO.OF CHILDREN:____TOBACCO USE: YES/NO HOW MUCH?______/DAY HOW LONG? DATE QUIT_____
ALCOHOL USE: HOW MUCH PER DAY?_______CAFFEINE (COFFEE,TEA,COLAS) PER DAY_____________
PAST ILLNESSES OF YOURSELF AND FAMILY:
YOU/YOUR FAMILY
YOU/YOUR FAMILY
YOU/YOUR FAMILY
ALCOHOLISM
HIGH BLOOD PRESSURE
STROKE
ANEMIA
KIDNEY DISEASE
SUICIDE ATTEMPT
ASTHMA
LIVER DISEASE
THYROID DISEASE
CANCER/TUMOR
HEPATITIS
TUBERCULOSIS, TB
DIABETES
LUNG DISEASE
ULCER IN GI TRACT
DRUG ABUSE
MENTAL ILLNESS
VENEREAL DISEASE
DEPRESSION
OSTEOARTHRITIS
HIGH CHOLESTEROL
EPILEPSY/SEIZURES
OSTEOPOROSIS
HIV/IMMUNE DX
GLAUCOMA
PHLEBITIS
OTHER_____________
HEART DISEASE
RHEUMATIC ARTHRITIS
PAST SURGICAL HISTORY: (PLEASE INCLUDE DATES)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
REVIEW OF SYSTEMS-PLEASE CHECK EACH ITEM “YES” OR “NO” AS THEY RELATE TO YOUR HEALTH:
CONSTITUTIONAL: Y
RESPIRATORY Yes No
es No
HEMATOLOGY/LYMPHYesNo
Weight Loss
Cough
Easy Bruising
Fatigue
Coughing Blood
Gums Bleed Easily
Fever
Wheezing
Enlarged Glands
Chills
EYES:
MUSCULOSKELETAL:
Glasses/Contacts
Joint Pain/Swelling
Eye Pain
Stiffness
GASTROINTESTINAL:
Double Vision
Heartburn/Reflux
Muscle Pain
Cataracts
Nausea/Vomiting
Back Pain
Constipation
EAR,NOSE,THROAT:
SKIN:
Difficulty Hearing
Change in BMs
Rash/Sores
Ringing in Ears
Diarrhea
Lesions
Vertigo
Jaundice
Itching/Burning
Sinus Trouble
Abdominal Pain
NEUROLOGICAL:
Nasal Stuffiness
Black or Bloody BM
Loss of Strength
Frequent Sore Throat
Numbness
GENITOURINARY:
Burning/Frequency
Headaches
CARDIOVASCULAR:
Murmur
Nighttime
Tremors
Chest Pain
Blood in Urine
Memory Loss
Palpitations
Erectile Dysfunction
FEMALES ONLY:
Dizziness
Abnormal Discharge
Date Last Mammogram_________
Fainting Spells
Bladder Leakage
Normal_____Abnormal_________
Shortness of Breath
ALLERGIC/IMMUNOLOGIC: Date last PAP_________________
Difficulty lying Flat
Hives/Eczema
Normal_____Abnormal_________
Swelling Ankles
Hay Fever
Age Onset Periods_____________
Age Onset Menopause__________
ENDOCRINE:
PSYCHIATRIC:
Loss of Hair
Anxiety/Depression
Periods Regular? Yes_____No____
Heat/Cold Intolerance
Mood Swings
Number Pregnancies____________
Difficult Sleeping
SIGNATURE/REVIEWING PHYSICIAN_________________________________________________________________________
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