Patient First Name(Required)Patient Last Name(Required)Email Date of Birth Month Day YearIn order to provide the best care we need to know your history. Please take a few minutes to answer all questions. Please add any information you feel will help explain your health. If you need any help with this form please ask us. Thank you.Patient Demographics and Chief ComplaintToday's Date Month Day YearAgeHeightWeightWho referred you to our practice?Have any of your family members been treated here?Why are you seeing the doctor today?When did you first have this problem?General Health Recurrent Infections Recurrent Fever Fatigue Night Sweats Recent Weight Gain Recent Weight Loss Decreased Appetite No ProblemsCommentsSkin Sores Hair Loss Non-healing wound Changes in moles New Lesions Burn Trauma Rash Lumps/growths No problemsCommentsHead, Ears, Eyes, Nose, Throat Ear Infections Nose Bleeding Cataracts Sore Throat Seasonal Allergies Eye Infections Headaches Corrective Lenses Blurred Vision No ProblemsCommentsLungs Difficulty Cough Sleep with more than 1 pillow Cough blood or mucus Wheezing No problemsCommentsBreast Breast Lump/mass Nipple Discharge Breast Pain Nipple Pain Breast Swelling Skin Changes No problemsCommentsHeart Chest Pain Tightness Thumping or Pounding Heart Murmer Swollen Arms or legs Shortness of Breath Rheumatic Fever High Blood Pressure No problemsCommentsStomach and Intestinal Special Diet Hearburn Rectal Bleeding Nausea Indigestion Blood in Stool Vomiting Black Stools Positive hemoccult Ulcers Constipation Diverticulitis Difficulty Swallowing Diarrhea Diverticulosis No problemsCommentsMale Reproductive Painful Urination Frequency Impotence Prostate problems Urgency Testicular pain No problemsCommentsFemale Reproductive Painful urination Frequency Blood clots Irregular periods Urgency No problemsCommentsMuscle, Bone, and Joint Joint Pain Neck Pain Muscle cramping Muscle pain Joint Stiffness Back Pain Joint Swelling No problemsCommentsNervous System Seizures Decreased memory Problems speaking Dizziness Fainting Problems moving Loss of consciousness No problemsCommentsVeins (Blood Vessels), Lymphatic Abnormal Bleeding Easy Bruising Anemia Enlarged lymph nodes No problemsCommentsAllergiesAre you allergic to any medications, prescribed or over the counter? Yes NoIf yes, please list the medication and the reaction you had. (Include aspirin, Tylenol, vitamins, over the counter medications, herbal remedies, supplements, etc...)Are you allergic to any contacts such as latex, adhesive tape, or betadine Yes NoIf yes, please list the contact and the reaction you had.Are you allergic to any foods? Yes NoIf yes, please list the food and the reaction you had.Family HistoryAre there diseases or illnesses that family members have had? Please check the boxes below for any family member who has had the problem. Under siblings please write brother or sister. Under Grandmother please write maternal (mother)or paternal (father). Under Grandfather please write maternal (mother) or paternal (father).Anesthetic Problems Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Breast Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Colon Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather Maternal) Children Cousins Aunt UncleCancer - Endometrial Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Ovarian Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Pancreatic Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Other Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleDiabetes Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleHeart Disease Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleHigh Blood Pressure Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Paternal) Children Cousins Aunt UncleMelanoma Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleMental Illness Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleStroke Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCommentsPast Medical HistoryDo you see a doctor regularly for any medical reasons? Yes NoIf yes, for what reason?Have you had surgery in the past? Yes NoIf yes, please list the date(s) and type of surgery.Have you ever had a colonoscopy? Yes NoIf yes, please list the date and the results.Have you had any serious injuries? Yes NoIf yes, please list the date and the type of injury.Have you had any diseases or health problems in the past? Yes NoIf yes, please check any of the following that you have had. Anemia Colitis Heart Disease High blood pressure Lung disease Cancer Diabetes Hepatitis A, B, or C Jaundice Depression Cataracts Glaucoma AIDS Kidney Disease Epilepsy Stroke Headaches HIV Leukemia Ulcers High Cholesterol Hypothyroidism Hyperthyroidism Sleep Apnea OtherPlease list any other diseases or health problems you have had here.Women's HistoryDate of first period? Month Day YearDate of last period? Month Day YearNumber of Pregnancies?Number of live births?Are you on hormone therapy? Yes NoIf yes, please describe.Do you do self breast exams? Yes NoWhen was your last mammogram? Month Day YearSocial HistoryWhat is your occupation? (If retired, your past occupation)Do you use NICOTINE products? No Smoke E-Cig/Vape Chewing TobaccoHave you ever used NICOTINE products? No Smoke E-Cig/Vape Chewing TobaccoIf yes, at what age did you quit?If yes, at what age did you quit?Do you drink alcoholic drinks? Yes NoIf yes, how much and how often?Do you take any drugs for reasons that aren not medical? Yes NoIf yes, please listMedications/Over The Counter/SupplementsDo you take any medicine (prescribed, herbal, over the counter, or health supplements?) Yes NoIf yes, please list below:MedicationDosageHow OftenWhat do you take it for? Add RemoveUse the + icon to add additional medications, if needed.Do you take blood thinners? Yes NoDo you take Metformin? Yes NoDo you take Aspirin daily? Yes NoDo you take diet pills? Yes NoDo you take vitamin E? Yes NoDo you take C-Pap machine? Yes NoDo you take Clucophage? Yes NoDo you take St. John's Wort? Yes NoDo you take fish oil? Yes NoPreferred Pharmacy
