Comprehensive Patient History Form (Page 2 of 2) in pdf

PLEASE ANSWER ALL QUESTIONS

Have you had any of the following during the past three months?

CONSTITUTIONAL

MUSCULOSKELETAL

Good general health lately…………………….. No

Joint pain……………….……………………… No

Yes

Recent weight change…………………………. No

Joint stiffness or swelling……………………… No

Yes

Fever…………………………………………... No

Weakness of muscles or joints………………… No

Yes

Fatigue………………………………………… No

Muscle pain or cramps………………………… No

Yes

Headaches……………………………………... No

Back pain………………………………………. No

Yes

EYES

Cold extremities………………………………... No

Yes

Eye disease or injury…………………………..

Difficulty in walking…………………………… No

Yes

Wear glasses/contact lens……………………..

Yes

SKIN

Blurred or double vision………………………

Rash or itching…………………………………. No

Yes

Glaucoma……………………………………...

Change in skin color…………………………… No

Yes

Change in hair or nails…………………………. No

ENT

Yes

Hearing loss…………………………………...

Varicose veins………………………………….. No

Yes

Ringing in the ears…………………………….

Breast pain……………………………………… No

Yes

Earaches or drainage…………………………..

Breast lump…………………………………….. No

Yes

Sinus problems………………………………...

Breast discharge………………………………… No

Yes

Nose bleeds……………………………………

Yes

NEUROLOGICAL

Mouth sores…………………………………… No

Frequent or recurring headaches………………... No

Yes

Bleeding gums………………………………… No

Light headed or dizzy…………………………... No

Yes

Bad breath or bad taste………………………... No

Convulsions or seizures………………………… No

Yes

Sore throat or voice change……………………. No

Numbness or tingling sensations……………….. No

Yes

Swollen glands in neck………………………… No

Tremors………………………………………… No

Yes

Paralysis………………………………………... No

CARDIOVASCULAR

Yes

Heart trouble…………………………………… No

Stroke…………………………………………… No

Yes

Chest pains…………………………………….. No

Head injury……………………………………… No

Yes

Sudden heart beat changes…………………….. No

Yes

PSYCHIATRIC

Swelling of feet, ankles or hands……………… No

Memory loss or confusion……………………… No

Yes

Nervousness……………………………………. No

RESPIRATORY

Yes

Frequent coughing……………………………... No

Depression……………………………………… No

Yes

Spitting up blood………………………………. No

Sleep problems…………………………………. No

Yes

Shortness of breath…………………………….. No

Yes

ENDOCRINE

Asthma or wheezing…………………………… No

Grandular or hormone problem………………… No

Yes

Thyroid disease………………………………… No

GASTROINTESTINAL

Yes

Loss of appetite………………………………… No

Diabetes………………………………………… No

Yes

Change in bowel movements………………….. No

Excessive thirst or urination…………………… No

Yes

Nausea or vomiting……………………………. No

Heat or cold intolerance……………………….. No

Yes

Frequent diarrhea………………………………. No

Dry skin………………………………………... No

Yes

Painful bowel movements or constipation…….. No

Change in hat or glove size……………………. No

Yes

Blood in stool………………………………….. No

Yes

HEMATOLOGIC/LYMPHATIC

Stomach pain…………………………………… No

Slow to heal after cuts…………………………. No

Yes

Easily bruise or bleed………………………….. No

GENITOURINARY

Yes

Frequent urination……………………………… No

Anemia…………………………………………. No

Yes

Burning or painful urination…………………… No

Phlebitis………………………………………… No

Yes

Blood in urine………………………………….. No

Past transfusion………………………………… No

Yes

Change of force of strain when urinating……… No

Enlarged glands………………………………… No

Yes

Incontinence or dribbling………………………. No

Yes

ALLERGIC/IMMUNOLOGIC

Kidney stones………………………………….. No

Yes

History of skin reaction or other adverse reactions to:

Sexual difficulty……………………………….. No

Penicillin or other antibiotics………… No

Yes

Male – testicle pain…………………………….. No

Yes

Morphine, Demerol or other narcotics.. No

Yes

Female – pain with periods…………………….. No

Novocaine or other anesthetics………. No

Yes

Female – irregular periods……………………… No

Aspirin or other pain remedies………. No

Yes

Female – vaginal discharge…………………….. No

Tetanus antitoxin or other serums…… No

Yes

Female – # pregnancies _____

Iodine, methiolate or other antiseptic… No

# miscarriages ______

Yes

Female – date of last pap smear ___________________

Other drugs/medications ______________________________

Female – findings of last pap smear ❏ Normal

❏ Abnormal

__________________________________________________

Date: ___________________________

Known food allergies _________________________________

Patient Signature: ___________________________________

Physician Signature: ______________________________________

Sylmar Medical Center, 14124 Foothill Blvd, Suite 100, Sylmar, CA 91342

Comprehensive Patient History Form Page 2

Related Articles

Related forms

Related Categories