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