Patient History Form Page 2

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SOCIAL   H ISTORY:    
Tobacco:  
No    
    Y es               P ack   p er   D ay:     _ ____  
Previous  
   
Alcohol:  
No  
    O ccas               F requent      
Amt:     _ ___________  
Drugs:      
No  
    Y es               P revious  
 
FAMILY   H ISTORY:  
Breast   c ancer:    
No  
Yes  
Relationship   /   A ge   a t   i llness:     _ _______________________  
Uterine   c ancer:  
No  
Yes  
Relationship   /   A ge   a t   i llness:     _ _______________________  
Ovarian   c ancer:  
No  
Yes  
Relationship   /   A ge   a t   i llness:     _ _______________________  
Colon   c ancer:    
No  
Yes  
Relationship   /   A ge   a t   i llness:     _ _______________________  
Other:  _________________________________________________________________________  
 
CURRENT   S YMPTOMS:   ( Circle   i f   p ositive)  
GENERAL:       f atigue,   f ever,   u nexplained   w eight   c hange,   b ody   a ches    
 
HEENT:     v ision   c hanges,   h earing   l oss,   p ersistent   s ore   t hroat  
BREASTS:     l umps,   t enderness,   d ischarge  
 
 
 
HEME/LYMPH:     e asy   b leeding,   e asy   b ruising,   e nlarged   l ymph   n odes  
SKIN:   r ash,   c hange   i n   m oles,   l umps    
 
 
 
CV:     c hest   p ain,   i rregular   h eart   b eat,   a nkle   s welling  
RESP:     s hortness   o f   b reath,   w heezing,   p ersistent   c ough  
 
 
GI:     n ausea,   v omiting,   d iarrhea,   c onstipation,   b lood   i n   s tools  
GU:     u rinary   i ncontinence,   u rgency,   f requency,   b urning  
 
 
IMMUNO:     a llergies,   s inus   c ongestion,   f requent   i llnesses  
NEURO:     m uscle   w eakness,   t ingling,   i ncoordination    
 
MUSCULOSKELETAL:     j oint   p ain,   m uscle   p ain,   b ack   p ain  
ENDOCRINE:     h ot   f lashes,   r educed   l ibido  
 
 
 
PSYCH:     a nxiety,   d epression,   d ifficulty   s leeping  
 
 
 
Year   l ast   m ammogram:     _ ______________________  
Location:     _ __________________________  
Year   l ast   c olonoscopy:     _ _______________________  
Physician:     _ _________________________  
Year   l ast   b one   d ensity:     _ ______________________  
Location:     _ __________________________  
 
Year   l ast   c holesterol   c hecked:     _ _________________  
 
 
 
 
 
 
 
Vaccines   r eceived/year:          
Gardasil/HPV     _ ______           F lu     _ ______         T etanus   _ ______           S hingles   _ ___         P neumonia   _ ____  
 
Primary   C are   P hysician:         _ ________________________________________________________  
 
 
 
 
 
 
 
 
 
 
 

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