Patient History

Patient Name_______________________________________________________ Todays Date__________________________________________

Date of Birth________________________________________________________ Occupation___________________________________________
Primary Care Provider_________________________________________________ Phone_______________________________________________
Referring Physician (if not PCP) _________________________________________Phone________________________________________________
Main Concern(s)/Reason for visiting today______________________________________________________________________________________
ALLERGIES (Please include type reaction to each allergy listed)

MEDICATIONS (Both prescription and over-the-counter including herbal, vitamins, etc) Please include another page if needed.
Name of medication and dosage

1.________________________________________________________ 5.____________________________________________________________
2.________________________________________________________ 6.____________________________________________________________
3.________________________________________________________ 7.____________________________________________________________
4.________________________________________________________ 8.____________________________________________________________
HOSPITALIZATION/SURGERIES/PROCEDURES (Please include exact date or at least year)
Personal History
FAMILY HISTORY (List of any problems of your SOCIAL HISTORY (Check all that apply)
Mother, father, siblings, children or grandparents only)
Current smoker

Yes

No

Number of stick per day_________

Alcohol use

Yes

No

Number of drinks per day________

Exercise
Family History

Yes

No

Number of days in a week______ Duration of exercise_______ type of exercise_______

PERSONAL HISTORY (Previous health problems)

1._______________________________________ 5._______________________________________9.____________________________________
2._______________________________________ 6._______________________________________10.___________________________________
3._______________________________________ 7._______________________________________11.___________________________________
4._______________________________________ 8._______________________________________12.___________________________________
REVIEW OF SYSTEM (Check current problems /symptoms you are experiencing now in past 1 month)

Weight gain
Weight loss
Fatigue
Easy bruising
Excessive sweating
Brittle nails
Rash
Change in skin
Dry skin color
Stretch mark
Darkening of skin
Peripheral vision loss
Worsening vision
Blurred vision
Bulging eyes
Headache
Double

Difficulty of breathing
Breast pain
Breast discharged
Breast enlargement
Chest pain/discomfort
Leg pain with exercise
Palpitation
Abdominal pain
Constipation
Diarrhea
Diarrhea with milk
Difficulty swallowing
Nausea
Vomiting
Pain with swallowing
Impotence
Abnormal periods

Pain in feet
Fractures
Muscle aches
Changing hand size
Changing font size
Dizziness
Painting
Weakness
Light headedness
Dizziness with standing
Changing concentration
Changing memory
Frequent false
Emotional swings
Numbness in hand/feet
Burning in hand/feet
Anxiety

Excessive urination
Feet intolerance

Hot flashes

Flashing

Excess face/body hair

Loss of hair

Decrease in height
Decrease in sex drive
Swollen glands

Neck lamp

Neck swelling

Muscle cramps

Muscle weakness

Pain in hands

Cold in tolerance

Excessive thirst

Neck pain (front)

Hoarseness
Snoring
Inability to smell
Change in dental bite
Change in head size
Pain in intercourse
Pain with urination
Kidney stones
Decrease in appetite
Depression
Difficulty of sleeping
Acne
Increase in appetite
Bone pain
Back pain
Joint pain
Feeling full before done eating

Other