Referred By: Patient Name:
DOB: Age:
CHIEF COMPLAINT:
Height: Weight:
Gender: Blood Type:
PAST MEDICAL HISTORY:
SURGICAL HISTORY:
Family History:
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):
Smoking History
Have You smoked 100 cigarettes in your life: YesNo
Smoking Status: Smoking Details:
Do you use tobacco: YesNo
Are you at risk of second hand smoke: YesNo
CURRENT MEDICATIONS:
Medication Name Dosage














How is Taken Prescribed By














CURRENT SUPPLEMENTS: (Please List)
ALLERGIES: Other:
REVIEW OF SYSTEMS AND CONDITIONS: (Please select/choose that apply)
CONSTITUTIONAL: ChillsFatigueFeverGeneralized PainHeadacheLiver CancerLung CancerNight SweatsPainSystemic IllnessWeight GainWeight LossOther
HEAD: Blurred VisionConcussiondizzinessFaintingHead SeizuresHead TraumaHeadacheMigraineSeizuresSinus ProblemVertigoOther (explain)
EYES: Blind SpotsBlurred Double VisionDiabetic Eye DiseaseDiminished Vision in both eyesDiminished Vision on the Left eyeDiminished Vision on the Right EyeDouble VisionDry EyesEye DiseaseEye PainGlasses Glaucoma InfectionItchingLight sensitivityMouth SoresNeck StiffnessPain behind EyesRetinitis PigmentosaScotsmanSinus ProblemVertigoVision ChangeVisual Blurring
EAR/NOSE/THROAT: Bleeding GumsBlurred VisionDenturesDysphasiaEar DrainageEarachesEpitasisHearing LossLight HeadedMouth SoresNeck StiffnessNodulesNose BleedsPost Nasal DripSinus ProblemSore ThroatThyroid NodulesTinnnitusTinnitusvertigovisualVertigoVoice Change
RESPIRATORY: AsthmaChest PainCoughDeviated SeptumDyspneaHeart Skip BeatHemophysis Hot FlashesNight SweatsNon-pruductive CoughOrthopneaPalpitationsParoxysmal Noctunal DispneaProductive CoughRespiratory InfectionsSorcoidosisShortness of BreathSleep ApneaSneezingSOBWheezing
CARDIOVASCULAR: ArteriosclerosisChest PainDispendEdemaExtremity PainExtremity SwellingFaintnessFatigueHeart ProblemHyperchlestorolHypertensionLeft BBBMurmurMVPPalpitationsWeak PulsePeripheral Vascular ConditionsPhlebitisShortness of BreathSynocopeVeriocositiesWeight Gain
GASTROINTESTINAL: Abdominal PainAbdominal StoolAcid RefluxAppetite ChangeBelchingBloatingChanges in Bowel HabitsColon ConditionConstipationDiarrheaDeverticuliosisFlatulence GallstonesHeartburnHemorrhoidsIncontinnceIndigestionNauseaRight Upper Quad. PainVomiting
GENITOURINARY: Bladder CancerBlood in UrineBurning/painful UrinationDysmenorreheaEnlarged ProstateFrequencyGenital SoresHerpesHesitancyIncontinenceKidney StonesLibidoBelchingMenstrual DisordersNacturiaOne PregnancyPenile ImplantPMS PainProstrateStrainingUrgencyUTIUTI for PregnancyVaginal DischargeVenereal Disease Explain
Female: Last Menstral Circle
MUSCULOSKELETAL: Ankle PainAnkle and Foot PainArthralgiaArthritis of the SpineArthritis of KneeArthritis of the PelvisAtrophyBack PainDifficulty WalkingElbow PainFibromyalgiaFoot Pain Hip PainJoint PainJoint StiffnessJoint SwellingJoint WeaknessKnee PainMenstrual PainMotion LimitationMuscle CrampsMuscle PainMuscle SpasmsMuscle Joint WeaknessNeck PainOsteoarthritis of SpineOsteoarthritis of the HipPain of hand/wristPelvis PainPeripheral NeuropathyPoor GripRedness of heat Muscle/jointsRheumatoid ArthritisShoulder PainSwellingTrouble WalkingWeakness of JointsWeakness of MusclesWrist/hand Pain
INTEGUMENTARY (SKIN CONDITIONS): AcneBoils of FaceChange in HairChange in NailsChange in skin colorDry SkinFacial ItchingFrequent HeadacheHair LossHair ThinningItchingJoint ItchLump on NeckMolesPigmentation/psoriasisRushSkin LesionsSun AllergySwelling Around EyesToenail FungusVaricose Veins
NEUROLOGICAL: AnxietyBrain FagConcentrationConcussionFrequent/recurringHeadachesMemory lossMood SwingsNervousnessNumbnessParalysisSleep ProblemStrokeTiaTingling SensationTremorsM.S.
PSYCHIATRIC: AnxietyAnxious and WorriedBipolarBrain FagConcentration LossConfusionDepressionDizzinessHallucinationsInsomniaLesion of the BrainMemory LossMood SwingsNervousness Opiate AddictionParathesiasisSleep ProblemGravingStressOther Condition
ENDOCRINE: Cold Intolerance Excessive Thirst Excessive Urination Glandular Problems Heat Intolerance Hormonal Problem Hyperthyroidism Thyroid Disease Thyroid Surgery Diabetis
HEMATOOGIC/LYMPHATIC: AnemiaBleeding easilyDelayed Wound HealingEnlarged GlandsPast TransfusionPhlebitisHypercholestorolemiaHep CIvig. ther Condition
ALLERGIE/IMMUNOLOGY: AlcoholAutoimmune DiseaseBeesCat AllergyDrug AllergyDrug interactionEnvironmental AllergiesFood AllergiesFrequent IllnessImmunodeficiencyImmunosupression InsectIodineMorphineSeasonal AllergiesSkin-RushesSugarOther
WEIGHT CONDITIONS:
Recent weight change and Please explain why: First sign of weight gain
Highest weight ever: Any measures taken for weight reduction. Please Explain:
Regular MD (provide name, address and phone number:
Specialists (provide name, address and phone number:
Date: Signature: _________________________
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