Today's Date

Your Full Name

Age

Who is your current Physician

Reason for switching Physician

List present medications (name/strength/number of times). Include over-the-counter drugs, herbal medicines, vitamins.

What medicines are you allergic to?

What surgeries have you had in the past and when?

What medical conditions are you being treated for now?

FAMILY MEDICAL HISTORY:

Do you have relatives who have had or currently have any of the following (please check all that apply):
Cancer High Blood Pressure    Diabetes
Heart Disease Arthritis    Bleeding Problems
Mental Illness     Stroke
Other:

REVIEW OF MEDICAL HISTORY

Check if you have or had problems.

General:
weight loss or gain    fatigue    weakness   
cancer:  type

Skin:
rashes    infections    skin condition:

Head:
headaches    head injuries

Eyes:
wear glasses    loss of vision    double vision

Ears:
hearing loss    ringing in ears    dizziness

Nose:
loss of smell

Throat:
difficulty swallowing    loss of taste
mouth or throat pain    dental problems

Lungs:
difficulty with breathing    asthma
pneumonia    tuberculosis
coughing up blood

Heart:
heart murmur    heart attack    high blood pressure    high cholesterol
angina

Abdomen:
stomach ulcer    gastritis    liver disease    hepatitis    gallbladder disorder
intestinal disorder    diverticulitis
other:

Kidney:
kidney stones    kidney disease

Urinary:
bladder infections    blood in urine
loss of control of urination

Genital (Men):
difficulty with erections    prostate problems

Genital (Women):
irregular period
menopause   
pregnancy:  how many?  normal? 

Endocrine:
diabetes    thyroid disease    hormone therapy

Skeletal:
broken bones    neck pain    back pain
leg pain    arm pain    arthritis

Muscle:
muscle weakness    muscle cramping    fibromyalgia    muscle disease

Blood:
bleeding disorder    anemia    AIDS

Neurologic:
seizures    stroke    paralysis
difficulty with speech

Psychologic:
depression    anxiety    treatment by psychiatrist    sleep difficulty

Other:

PERSONAL INFORMATION:

Marital Status:
single    married    divorced    widowed

Occupation

Do you smoke?  yes    no
If no, how much?

Do you drink alcohol?  yes    no
If yes, how much?

Have you used cocaine/heroin/marijuana?
yes    no

Have you been treated for drug or alcohol use?
yes    no

Your current weight is: