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: _____________________________________________________________________________