Forms

Atlantic Integrative Medical Center
Chief Complains, Medical History & Review Of Systems

Must be completed by patient before his/her first physical examReferred By :Patient Name :D.O.B. :Age :CHIEF COMPLAINT :Height :Weight :Gender :Blood Type :Please explain (Present illness, how long?, When the symptoms begin?)PAST MEDICAL HISTORY :SURGICAL HISTORY :FAMILY HISORY :Mothers age (at death if deceased) :Fathers age (at death if deceased) :Any medical conditions :Other family members / chronic conditions :Social History (Circle Habits that Apply) :Coffee/Tea Cola/Soda Alcohol Beverages Salt Sugar Other/SpecifySmoking History :Have You smoked 100 cigarettes in your life :

Yes
No

Smoking Status :Smoking Details :Do you use tobacco :

Yes
No

Are you at risk of second hand smoke :

Yes
No

CURRENT MEDICATIONS :

Medication Name Dosage How is Taken Prescribed By

CURRENT SUPPLEMENTS : (Please List)ALLERGIES:  REVIEW OF SYSTEMS & CONDITIONS : (Please select/choose that apply)CONSTITUTIONAL : Chills Fatigue Fever Generalized Pain Headache Liver Cancer Lung Cancer Night Sweats Pain Systemic Illness Weight Gain Weight Loss OtherHEAD : Blurred Vision Concussion dizziness Fainting Head Seizures Head Trauma Headache Migraine Seizures Sinus Problem Vertigo Other (explain)EYES : Blind Spots Blurred Double Vision Diabetic Eye Disease Diminished Vision in both eyes Diminished Vision on the Left eye Diminished Vision on the Right Eye Double Vision Dry Eyes Eye Disease Eye Pain Glasses Glaucoma Infection Itching Light sensitivity Mouth Sores Neck Stiffness Pain behind Eyes Retinitis Pigmentosa Scotsman Sinus Problem Vertigo Vision Change Visual BlurringEAR/NOSE/THROAT : Bleeding Gums Blurred Vision Dentures Dysphasia Ear Drainage Earaches Epitasis Hearing Loss Light Headed Mouth Sores Neck Stiffness Nodules Nose Bleeds Post Nasal Drip Sinus ProblemSore Throat Thyroid Nodules Tinnnitus Tinnitusvertigovisual Vertigo Voice ChangeRESPIRATORY : Asthma Chest Pain Cough Deviated Septum Dyspnea Heart Skip Beat Hemophysis Hot Flashes Night Sweats Non-pruductive Cough Orthopnea Palpitations Paroxysmal Noctunal Dispnea Productive Cough Respiratory Infections Sorcoidosis Shortness of Breath Sleep Apnea Sneezing SOB WheezingCARDIOVASCULAR : Arteriosclerosis Chest Pain Dispend Edema Extremity Pain Extremity Swelling Faintness Fatigue Heart Problem Hyperchlestorol Hypertension Left BBB Murmur MVP Palpitations Weak Pulse Peripheral Vascular Conditions Phlebitis Shortness of Breath Synocope Veriocosities Weight GainGASTROINTESTINAL : Abdominal Pain Abdominal Stool Acid Reflux Appetite Change Belching Bloating Changes in Bowel Habits Colon Condition Constipation Diarrhea Deverticuliosis Flatulence Gallstones Heartburn Hemorrhoids Incontinnce Indigestion Nausea Right Upper Quad. Pain VomitingGENITOURINARY : Bladder Cancer Blood in Urine Burning/painful Urination Dysmenorrehea Enlarged Prostate Frequency Genital Sores Herpes Hesitancy Incontinence Kidney Stones Libido Belching Menstrual DisordersNacturia One Pregnancy Penile Implant PMS Pain Prostrate Straining Urgency UTI UTI for Pregnancy Vaginal Discharge Venereal Disease Explain Female : Last Menstral Cicle MUSCULOSKELETAL : Ankle Pain Ankle & Foot Pain Arthralgia Arthritis of the Spine Arthritis of Knee Arthritis of the Pelvis Atrophy Back Pain Difficulty Walking Elbow Pain Fibromyalgia Foot Pain Hip Pain Joint Pain Joint Stiffness Joint Swelling Joint Weakness Knee Pain Menstrual Pain Motion Limitation Muscle Cramps Muscle Pain Muscle Spasms Muscle Joint Weakness Neck Pain Osteoarthritis of Spine Osteoarthritis of the Hip Pain of hand/wrist Pelvis Pain Peripheral Neuropathy Poor Grip Redness of heat Muscle/joints Rheumatoid Arthritis Shoulder Pain Swelling Trouble Walking Weakness of Joints Weakness of Muscles Wrist/hand PainINTEGUMENTARY (SKIN CONDITIONS) : Acne Boils of Face Change in Hair Change in Nails Change in skin color Dry Skin Facial Itching Frequent Headache Hair Loss Hair Thinning Itching Joint Itch Lump on Neck MolesPigmentation/psoriasis Rush Skin Lesions Sun Allergy Swelling Around Eyes Toenail Fungus Varicose VeinsNEUROLOGICAL : Anxiety Brain Fag Concentration Concussion Frequent/recurring Headaches Memory loss Mood Swings Nervousness Numbness Paralysis Sleep Problem Stroke Tia Tingling Sensation Tremors M.S.PSYCHIATRIC : Anxiety Anxious & Worried Bipolar Brain Fag Concentration Loss Confusion Depression Dizziness Hallucinations Insomnia Lesion of the Brain Memory Loss Mood Swings Nervousness Opiate Addiction Parathesiasis Sleep Problem Graving Stress Other ConditionENDOCRINE : Cold Intolerance Excessive Thirst Excessive Urination Glandular Problems Heat Intolerance Hormonal Problem Hyperthyroidism Thyroid Disease Thyroid Surgery DiabetisHEMATOOGIC/LYMPHATIC : Anemia Bleeding easily Delayed Wound Healing Enlarged Glands Past Transfusion Phlebitis Hypercholestorolemia Hep C Ivig. ther ConditionALLERGIE/IMMUNOLOGY : Alcohol Autoimmune Disease Bees Cat Allergy Drug Allergy Drug interaction Environmental Allergies Food Allergies Frequent Illness Immunodeficiency Immunosupression Insect Iodine MorphineSeasonal Allergies Skin-Rushes Sugar OtherWEIGHT CONDITIONS : Recent weight change & Please explain why:  Overweight ( BMI 25-29) Obese,(BMI 30-39) First sign of weight gain  Highest weight ever:  lb, Any measures taken for weight reduction. Please Explain: Regular MD (provide name, address & phone number :Specialists (provide name, address & phone number :Date :       Signature _______________________

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