MaleFemale

CURRENT MEDICATIONS

NoYes

Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:
S.No. Name of drug How long did you take it? Please list side effects:
1
2
3
4
PAST MEDICAL HISTORY
Do you now or have you ever had:
DiabetesHigh blood pressureHigh cholesterolHypothyroidismGoiterCancerLeukemiaPsoriasisAnginaHeart problems Heart murmurPneumoniaPulmonary embolismAsthmaEmphysemaStrokeEpilepsy (seizures)CataractsKidney diseaseKidney stones Crohn’s diseaseColitisAnemiaJaundiceHepatitisStomach or peptic ulcerRheumatic feverTuberculosisHIV/AIDS

PERSONAL HISTORY

High schoolSome collegeCollege graduate Advanced degree

Never marriedMarriedDivorcedSeparatedWidowedPartnered/significant other

YesNo

retireddisabledsick leave?

YesNo

SYSTEMS REVIEW
In the past month, have you had any of the following problems?

Recent weight gainRecent weight lossFatigueWeaknessFeversweats

HeadachesDizzinessFainting or loss of consciousnessNumbness or tinglingMemory loss

DepressionExcessive worriesDifficulty falling asleepDifficulty staying asleepDifficulties with sexual arousalPoor appetiteFood cravingsFrequent cryingSensitivityThoughts of suicide / attemptsStressIrritabilityPoor concentrationRacing thoughtsHallucinationsRapid speechGuilty thoughtsParanoiaMood swingsAnxietyRisky behavior

NumbnessJoint painMuscle weaknessJoint swelling

NauseaHeartburnStomach painVomitingYellow jaundiceIncreasing constipationPersistent diarrheaBlood in stoolsBlack stools

Ringing in earsLoss of hearing

AnemiaClots

Frequent sore throatsHoarsenessDifficulty in swallowingPain in jaw

RednessRashNodules/bumpsHair lossColor changes of hands or feet

PainRednessLoss of visionDouble or blurred visionDryness

Chest painPalpitationsShortness of breathFaintingSwollen legs or feetCough

Frequent or painful urinationBlood in urine

Abnormal Pap smearIrregular periodsBleeding between periodsPMS

WOMENS REPRODUCTIVE HISTORY:

YesNo

YesNo

SUBSTANCE USE
DRUG CATEGORY (circle each substance used) Age when you first used this: How much & how often did you use this? How many years did you use this? When did you last use this? Do you currentlyuse this?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo