Confidential Medical History - Diagnostic Center of Medicine

DIAGNOSTIC CENTER OF MEDICINE
-CONFIDENTIAL MEDICAL HISTORY FORM-
Patient Name: _____________________________________________________
Patient # _____________________
Referred By [If Any] ________________________________________________
Date: _______________________
Please answer all questions. If you do not know the answer, or do not understand the question, insert a question
mark in the space. Please leave no blanks.
Characterize your present health status:
GENERAL HEALTH AND HABITS
Excellent
Very Good
Average
Poor
Exercise
Do you exercise regularly? Yes
No
Type of exercise ______________________________________
How often? ___________ days/weeks for _________ minutes
Nutrition
Weight: Now _____ 5yrs ago _____ 10yrs ago _____
Appetite? Excellent
Good
Fair
Poor
Foods you avoid? _____________________________
Smoking
Do you smoke? Yes
No
How many per day ____________ for how long ___________
What do you smoke? Cigarettes
Pipe
Cigars
Other
How long have/had you smoked? ________________________
When did you quit smoking? ____________________ years ago
Alcohol/Beverage
Estimate the amount of alcohol you drink regularly:
_________ drinks per day _________ drinks per week
Did you formerly drink? Yes
No
Estimate the amount of caffeinated beverages you
drink daily: ________________ glasses, cups, or cans
*One Drink= 1 can Beer, 4 oz. Wine, or 1 oz. of Liquor
Drugs
Do you currently use recreational or street drugs? Yes
Have you ever given yourself street drugs with a needle?
No
Yes
No
If yes, which one[s]? __________________
____________________________________
PAST MEDICAL AND SURGICAL HISTORY
List chronologically all the surgery you have had, indicating the nature of each operation and where/when it was done
YEAR
OPERATION
HOSPITAL
YEAR
List chronologically all hospitalization not already mentioned [Not including Childbirth]
OPERATION
HOSPITAL
IMMUNIZATIONS
Tetanus
Shingles
Influenza
Pneumonia
Date: ____________
Date: ____________
Date: ____________
Date: ____________
Hepatitis A
Hepatitis B
Chickenpox
HPV
Date: _____________
Date: _____________
Date: _____________
Date: _____________
MEDICATIONS
Please list any and all current medications, including vitamins and supplements.
NAME OF DRUG
STRENGTH
FREQUENCY
START DATE
Please list any and all allergies to medication, food, and other
ALLERGY
REACTION
PERSONAL HISTORY
Where were you born? __________________________
Health Maintenance:
Have you ever lived or travel abroad? Yes
No
If so, where? __________________________________
Dental Exam
Date: ____________
Are you currently sexual active? Yes
No
Annual Vision Exam
Date: ____________
What is your occupation? ________________________
EKG
Date: ____________
What, if any, chemicals or particles are you exposed to
Chest X-Ray
Date: ____________
at work? ______________________________________
Dexa Scan/Bone Density Date: ____________
Do you enjoy your work or retirement? Yes
No
STD Testing
Date: ____________
Have you ever worked in the field of medicine?
Tuberculosis Skin Test
Date: ____________
[Including volunteer, aide, clerk, ext…] Yes
No
WOMEN ONLY
At what age did you begin to menstruate? ____________
Are you pregnant or breastfeeding? Yes
No
Date of last Menstruation/Menopause: ______________
Number of Pregnancies _____ Number of Births _____
Length of period: _________ Cycle Length: ___________
Have you ever had a hysterectomy? Yes
No
Are your periods regular? Yes
No
Are you taking birth control/hormones? Yes
No
Heavy periods, spotting, pain, or discharge? Yes
No
If yes, what are you taking? _______________________
Any urinary tract, bladder, or kidney infections within the last year?
Yes
No
Have you ever had tumor[s], cyst[s], or another breast disease?
Yes
No
When was your last mammogram? _____________ Results ___________________ Self Breast Exams? Yes
No
When was your last pap smear? _______________ Results ___________________
When was your last rectal exam? ______________ Colonoscopy? __________________ Results ___________________
MEN ONLY
Do you feel pain or burning with urination? Yes
No
Any bladder, prostate, or kidney infections within the last year? Yes
No
Any difficulty with erection or ejaculation? Yes
No
Any testicle pain or swelling? Yes
No
When was your last prostate exam? ____________ Last PSA? ______________________ Results ___________________
When was your last rectal exam? ______________ Colonoscopy? __________________ Results ___________________
PERSONAL SAFETY 65+ ONLY
Do you live alone? Yes
No
Do you have an Advance Directive or Living will? Yes
No
Do you have vision or hearing loss? Yes
No
Do you have frequent falls? Yes
No
Have you ever been a victim of any type of elderly abuse, either mental or physical?
Yes
No
REVIEW OF SYSTEMS
Do you currently have or have you ever had any of the following? Answer all questions. If you do not understand the
question, insert a question mark.
URINARY
YES NO
Kidney Disease/Nephritis
Protein/Albumin in Urine
Blood/Pus in Urine
Kidney Stones
Urinary Infection
Prostate Trouble
Syphilis or Gonorrhea
Discomfort with
Urination
Ever had a Kidney X-Ray?
How many times do you urinate at
night? _________________________
During the day? _________________
HEMATLOGY/
ONCOLOGY
Anemia
Bleeding/Bruising easily
Cancer or Tumor
Radiation Treatment
YES
NEUROLOGICAL
Neurological Disease
Frequent Headaches
Loss of Consciousness
Convulsions/Seizures
Head Injury
Stroke
Paralysis/Muscle
Weakness
Tremor/Abnormal
Movements
Difficulty in Walking
Difficulty in Speaking
Double Vision/Loss of
Vision
Numbness
Difficulty with Memory
Dizziness
YES
SENSES
Glaucoma
Other Major Eye Disease
Deafness
Abnormal Noises in Ear
YES
ALLERGY/IMMUNOLOGY
Asthma
Eczema
Other Skin Problems
Hay Fever
Sinuses
YES
NO
NO
NO
NO
MOOD
Anxiety/Panic Attacks
Phobias
Hard to Concentrate
Unable to enjoy usual
activities
Weight Change
Eating Disorder
Insomnia
Daytime Sleepiness
Feelings of
worthlessness
Excessively Fatigued
Depressed
Nervous Breakdown
Drug or Alcohol Problem
Psychiatric Care
YES
NO
SEXUAL
Any History of STD
Discomfort during
Intercourse
Sexual Difficulties
Trying for Pregnancy
YES
RESPIRATORY
Pneumonia
Severe Bronchitis
Pleurisy
Tuberculosis
Wheezing
Chronic Bronchitis
Emphysema
Other Lung Troubles
Exposure to dangerous
dust or fumes
Trouble Breathing
Excessive Snoring
Chest Pain
Abnormal Chest X-Ray
Coughed Up Blood
Regularly Cough
Regularly Raise Sputum
YES
NO
JOINTS
Muscle Pain
Back Pain
Joint Pain
Joint Swelling
Gout
Arthritis
Rheumatism
YES
NO
CIRCULATORY
Abnormal Cardiac Test
Heart Trouble
Heart Attack
Angina Pectoris
High Cholesterol
High Blood Pressure
Blackouts
Racing of Heart
Rheumatic Fever
Heart Failure
Swelling of Ankles
YES
NO
ENDOCRINOLOGY
Hormone Problems
Thyroid Disease
Diabetes
Osteoporosis
YES
NO
DIGESTIVE
Poor Appetite
Trouble Swallowing
Heartburn
Regurgitation
Nausea/Vomiting
Abdominal Pain
Constipation
Diarrhea
Hiatal/Esophageal
Hernia
Duodenal/Gastric Ulcer
Vomiting of Blood
Black or Tarry Stools
Blood in Stool
Yellow Jaundice
Liver Trouble
Hepatitis
Gallbladder Trouble or
Stones
Colitis
Diverticulitis
Parasite Infection
Hernia
Changes in Bowels
Other Digestive Disease
Ever had an Upper GI?
Gallbladder XRay/Ultrasound
YES
NO
CUTANEOUS
Skin Rashes
Skin Cancer
YES
NO
NO
FAMILY HEALTH HISTORY
Please give the following information about the health of your immediate family
Check if Unknown or Adopted
RELATION
AGE IF ALIVE AGE AT DEATH
SIGNIFICANT HEALTH PROBLEMS / CAUSE OF DEATH
FATHER
MOTHER
BROTHERS
AND
SISTERS
CHILDREN
Have any blood relatives ever had any of the following? If so, please indicate relationship.
Diabetes
Migraines
Allergies
Alcoholism
Heart Attack
Cancer
Seizures/Epilepsy
Blood Disease
Psychiatric Disease
High Blood Pressure
Abnormal Bleeding
Kidney Disease
Other
MEDICAL PROBLEMS
Please list ALL medical problems you have been diagnosed with
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SPECIALISTS
Please list any and all Specialist or other Doctors that you are presently seeing
NAME OF DOCTOR
SPECIALTY
PHONE
LAST VISIT
SIGNATURE OF PATIENT: _____________________________________________________________________________