Patient Name:

Date of birth:

Who is your eye doctor?

When was your last eye examen:

Who is your gastroenterologist(GI)?

Name:

When was your last colonoscopy

Who is your gynecologist (if is applicable)?

When was your last PAP smear:

When was your last mammogram:

Please list any other specialist you see that were not mentioned above:

Speciality

Name

Phone number

Speciality

Name

Phone number

Speciality

Name

Phone number

Speciality

Name

Phone number

HandednessLR

Present Concerns:

Have you ever had:

Chicken PoxNoYes

HepatitisNoYes

Scarlet FeverNoYes

TuberculosisNoYes

Rheumatic FeverNoYes

PneumoniasNoYes

PolioNoYes

Venereal DiseaseNoYes

Blood TransfusionsNoYes

Have you ever been treated for:

AsthmaNoYes

Thyroid DiseaseNoYes

EmphysemaNoYes

DiabetesNoYes

Heart AttackNoYes

AnemiaNoYes

Heart FailureNoYes

CancerNoYes

Heart MurmurNoYes

Kidney DiseaseNoYes

Abnormal HeartbeatNoYes

Kidney StoneNoYes

High Blood PressureNoYes

Ulcer DiseaseNoYes

ColitisNoYes

Gall Bladder DiseaseNoYes

Blood ClotsNoYes

ArthritisNoYes

StrokeNoYes

GoutNoYes

Epilepsy(seizures)NoYes

Abnormal CholesterolNoYes

Psychiatric DisorderNoYes

Chronic Allergies, GlaucomaNoYes

Hay FeverNoYes

Colon PolypsNoYes

Other problems not listed above:

Last Colonscopy: 

Last Stress Test: 

List any operations that you have had (include approximate age): 

Have you ever been treated with X-RAY therapy or radioactive drugs?NoYes

List any medications (and dosages) you currently are taking (include over-the-counter drugs):

Habits

Tobacco use?NoYes

Did you quit?NoYes

Alcohol?NoYes

Coffee, tea or cola?NoYes

Do you exercise regularly?NoYes

What kind of work do you do? 

Any toxic exposure?NoYes

What method of contraception do you use (if applicable)?

Do any of your family members have or have had:

Family History:

Age

Illness

Cancernoyes

Father:

Heart AttacksNoYes

Mother:

High blood pressureNoYes

Brothers:

StrokesNoYes

Sisters:

Thyroid diseaseNoYes

Sons:

DiabetesNoYes

Daughters:

AnemiaNoYes

Other:

Kidney diseaseNoYes

UlcersNoYes

OtherNoYes

Are you bothered with:

Skin Rashes or DiscolorationNoYes

Loss of Consciousness(Fainting)NoYes

Abnormal Lumps or GlandsNoYes

Unusual or Serious Visual ProblemsNoYes

Nausea or VomitingNoYes

Hearing, Problems, EarachesNoYes

Belly PainNoYes

HeadachesNoYes

ConstipationNoYes

Frequent ColdsNoYes

DiarrheaNoYes

HoarsenessNoYes

Bloody or Tarry StoolsNoYes

Frequent or Persistent CoughNoYes

Excessive or Constant WorryingNoYes

Feeling Lonely or DepressedNoYes

Abnormal TirednessNoYes

Inability to Sleep WellNoYes

Shortness of BreathNoYes

Mood SwingsNoYes

WheezingNoYes

Poor AppetiteNoYes

Chest PainNoYes

Difficulty SwallowingNoYes

Skipped or Irregular HeartbeatNoYes

HemorrhoidsNoYes

Ankle SwellingNoYes

Trouble UrinatingNoYes

Pain in your Legs when you walkNoYes

ArthritisNoYes

Weakness in your Arms or LegsNoYes

Morning StiffnessNoYes

Loss of Sensation (numbness)NoYes

Fever or ChillsNoYes

LightheadednessNoYes

Impotence or Other Sexual DifficultyNoYes

Night SweatsNoYes

BruisesNoYes

Weight LossNoYes

Weight GainNoYes

Please give details of any yes answers or of other symptoms not listed above

Please list any other doctors you currently see:

Female Patients - Do you have any problems with:

CrampsNoYes

Heavy BleedingNoYes

IrregularNoYes

DischargeNoYes

Painful intercourseNoYes

Last Breast Exam/Mammogram  

Your last menstrual period? 

Last Pap Smear  

Last Bone Density Scan  

Number of pregnancies and any complications  

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