PATIENT'S PERSONAL HISTORY Patient No. _________________
Date ______________________
Confidential Record: Information contained here will not he released except when you have authorized us to do so.
Please print the forms and fill them out. You may mail them to our office or bring them to your office visit.
| Last Name ______________________ | First _______________________ | Middle ______________________ |
| Birth Date | _________________________ | Birth Place | ___________________________ |
| Address | _________________________ | City | ___________________________ |
| State | _________________________ | Zip | ___________________________ |
| Home Phone | _________________________ | Business Phone | ___________________________ |
| Occupation | __________________ | Medicare No. | _________________ | S.S. Number | _____________________ |
| Sex | __________________ | Marital Status | _________________ | Religion | _____________________ |
| Employer | ___________________________ | Employer Phone Number | ___________________________ |
| Person to Notify | ___________________________ | Relationship | ___________________________ |
| Address | ___________________________ | Phone Number | ___________________________ |
| Date of Last Physical Examination | ___________________________ | Doctor | ___________________________ |
| Family or Referring Physician | ___________________________ | Address | ___________________________ |
| Drivers License No. | ___________________________ |
Do you know of any blood relative who has or had (Circle and give relationship):
| Stroke | ______________________ | Migraine | __________________ | Arthritis | ______________________ |
| Cancer | ______________________ | Asthma | __________________ | Bipolar illness | ______________________ |
| Hypertension | ______________________ | Hay Fever | __________________ | Colitis | ______________________ |
| Anemia | ______________________ | Goiter | __________________ | Kidney disease | ______________________ |
| Tuberculosis | ______________________ | Bleeding tendency | __________________ | Depression | ______________________ |
| Diabetes | ______________________ | Severe allergies | __________________ | Other heartdisease | ______________________ |
| Leukemia | ______________________ | Heart Attack | __________________ | Rheumatic heart | ______________________ |
| Epilepsy | ______________________ | Stomach ulcers | __________________ | Suicide | ______________________ |
| FAMILY HISTORY | If Living | If Deceased | ||||
| Sex | Age | Health | Age at Death | Cause | ||
| Father | ||||||
| Mother | ||||||
| Brothers / Sisters (circle one) | ||||||
| M | F | |||||
| M | F | |||||
| M | F | |||||
| M | F | |||||
| M | F | |||||
| Husband /Wife | ||||||
| Sons / Daughters (circle one) | ||||||
| M | F | |||||
| M | F | |||||
| M | F | |||||
| M | F | |||||
| M | F | |||||
* Since some names may be used for either men or women, please circle sex for each Brother, Sister, Son or Daughter
PERSONAL HABITS (Circle):
Yes No Have you regularly smoked? Cigarettes Pipe Cigars For how many years?______ No. per day_______
Yes No Do you usually drink over 6 cups of coffee per day?
Yes No Do you regularly drink alcohol? 1 oz. per day 2 oz. per day 4 oz. per day
BEER: 1 bottle per day 2 bottles per day over 4 bottles per day
Are you presently taking any of the following medications? (Circle)
| Yes No Aspirin, bufferin, anacin | Yes No Tranquilizers |
| Yes No Blood pressure pills | Yes No Weight-reducing pills |
| Yes No Cortisone | Yes No Blood-thinning pills |
| Yes No Cough medicine | Yes No Dilantin |
| Yes No Digitalis | Yes No Shots |
| Yes No Hormones | Yes No Water pills |
| Yes No Insulin or diabetic pills | Yes No Antibiotics |
| Yes No Iron or poor blood medications | Yes No Barbiturates |
| Yes No Laxatives | Yes No Birth control pills |
| Yes No Sleeping pills | Yes No Phenobarbital |
| Yes No Thyroid medicine | Yes No Other drugs not listed |
Write in the names and year of any operations which you have had:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Name any drugs to which you are allergic:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Write in the names of any diseases you have had which required hospitalization:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Serious illnesses which you have had (not requiring hospitalization):
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Serious injuries or accidents (include broken bones or fractures):
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Transfusions: Yes / No Date ______________
Have you ever had any of the following illnesses? (Circle)
| German measles | Pneumonia | Heart disease | Syphilis or "Bad Blood" |
| Mumps | Pleurisy | Kidney disease | Asthma |
| Whooping cough | Tuberculosis | High blood pressure | Arthritis or Rheumatism |
| Chicken pox | Jaundice or Liver trouble | Diabetes | Scarlet fever |
| Measles | Palsy (Chorea) | Thyroid trouble | Rheumatic fever |
Immunizations: (Give date)
| DPT | Smallpox | T.B. Skin test |
| Polio | Tetanus | Others? |
To be answered by WOMEN only: (Circle)
Yes No Are you still having regular monthly menstrual periods?
Yes No Have you ever had bleeding between your periods? When? _______________________________
Yes No Do you have very heavy bleeding with your periods? When? _______________________________
How far apart are your periods? ______________________________________
Yes No Are you now on or have you ever taken the birth control pill? When? _______________________________
Yes No Have you ever had a discharge from the nipple of your breast? When? _______________________________
Yes No Lump in the breast? Pin in breasts? When? _______________________________
Yes No Do you regularly have the cancer test of the cervix? Date of last test________________________
Yes No Ever have an abnormal cancer test? When? _______________________________
Yes No Do you have severe pain with your periods?
Yes No Do you have pain with sexual relations?
Yes No Did any of your children weigh over 9 pounds at birth?
Yes No Have you been through menopause (change of life)?
Yes No Any bleeding or spotting since menopause?
What form of contraception are you using?______________________________________________________________
How many children born alive_______________________________ How many miscarriages _____________________
How many stillbirths_______________________________________ How many cesarean operations_______________
How many premature births_________________________________ Any complication of pregnancy _______________
Date of last menstrual period_________________________________ Date of period before last ___________________
To be answered by men and women:
Your present weight____________________________ Your weight 1 year ago _________________________
Your usual weight______________________________ Your weight 2 years ago ________________________
Circle "Yes" or"No":
| Yes No Have you served in the military? | Yes No Ever rejected or rated up for insurance? |
| Yes No Were you medically discharged? | Yes No Do you have trouble sleeping? |
| Yes No Ever been refused a job for health reasons? | Yes No Do you have skin problems (itching, rash, other)? |
| Yes No Have you had a mole change color or size? | Yes No Do you need glasses? |
| Yes No Have you had any skin tumors? | Yes No Do you have glaucoma? |
| Yes No Have you noticed any changes in your hair or nails? | Yes No Do you often see double? |
| Yes No Have you been rejected as a blood donor? | Yes No Are your eyes often red or inflamed? |
| Yes No Do you bleed or bruise easily? | Yes No Ever been told you have cataracts? |
| Yes No Do you frequently have a painful or swollen tongue? | Yes No Are you hard of hearing? |
| Yes No Have you been exposed to loud noises for long periods? | Yes No Ever have recurrent ear infections? |
| Yes No Do you have ear pains? | Yes No Ever have ringing in ears? |
-----------------------------------------------------------------------------------------------------------------------------
Yes No Do you frequently have severe headaches? (If "Yes ",answer the following)
Yes No Do they cause visual trouble?
Yes No Do they occur on one side of the head?
Yes No Do they awaken you from sleep?
Yes No Do they feel like a tight hat band?
Yes No Do they hurt most in the back of the head and neck?
Yes No Does aspirin relieve them?
Yes No Are headaches common in your family?
-----------------------------------------------------------------------------------------------------------------------------
| Yes No Have you ever fainted? | Yes No Frequently feel faint? |
| Yes No Frequent weakness of any body part? | Yes No Have you ever had a convulsion? |
| Yes No Recurrent numbness or tingling anywhere in your body? | Yes No Frequent severe dizziness? |
| Yes No Any paralysis? |
-----------------------------------------------------------------------------------------------------------------------------
| Yes No Do you often have bad sneezing spells? | Yes No Do you frequently have trouble swallowing? |
| Yes No Is your nose often stuffed up? | Yes No Hoarseness or voice change? |
| Yes No Nosebleeds? | Yes No Have you lost more than half of your teeth? |
| Yes No Treatment for sinus trouble? | Yes No Often have toothaches? |
| Yes No Have hay fever? |
-----------------------------------------------------------------------------------------------------------------------------
Have you ever had shortness of breath: (Circle)
| Yes No Doing your usual work? | Yes No Climbing a flight of stairs? |
| Yes No Which awakens you at night? | Yes No Which causes you to cough? |
| Yes No Accompanied by wheezing? | Yes No Do you have a chronic cough? |
| Yes No Do you frequently have heavy chest colds? | Yes No Do you cough up much sputum? |
| Yes No Have you ever coughed up blood? | Yes No Have you soaking sweats at night? |
| Yes No Ever have a chronic chest condition? | Yes No Ever have an abnormal chest X-ray? |
-----------------------------------------------------------------------------------------------------------------------------
Have you ever had chest pain or tightness in the chest which begins when: (Circle)
| Yes No Exerting yourself? | Yes No Walking against the wind? |
| Yes No Walking up a hill? | Yes No After a heavy meal? |
| Yes No When upset or excited? Radiates down one arm? | Yes No Disappears if you rest? |
| Yes No Occurs only at rest? When walking fast? | Yes No In cold or hot weather? |
| Yes No Do you have bothersome heart thumping (palpitatition)? | Yes No Does your heart often race? |
| Yes No Do you sleep on more than one Pillow? | Yes No Ever been told you have a heart murmur? |
| Yes No Ever have an EKG (Cardiogram)? | |
| Yes No If you have chest pain or tightness, please explain:_________________________________________________ | |
-----------------------------------------------------------------------------------------------------------------------------
Have you recently had pain in the stomach which: (Circle)
| Yes No Occurs 1 - 2 hours after a meal? | Yes No Is brought on by fried, spicy or gassy food? |
| Yes No Awakens you at night? | Yes No Is relieved by antacids? |
| Yes No Is helped by milk or eating? | Yes No Occurs while eating or immediately after? |
| Yes No Is relieved by a bowel movement? | Yes No Ever had ulcers? |
| Yes No Frequent nausea and vomiting? | Yes No Poor appetite? |
| Yes No Ever have X-rays of stomach, colon or gallbladder? | Yes No Have frequent bowel movements? |
If you have had a change in bowel habits recently, answer the following:
| Yes No Crampy pain in the abdomen? | Yes No Alternating diarrhea and constipation? |
| Yes No Pain during or after bowel movement? | Yes No Mucus in the stool? |
| Yes No Blood in the stool? | Yes No Ribbon-like stools? |
| Yes No Black stools? | Yes No Require strong laxatives or enemas? |
-----------------------------------------------------------------------------------------------------------------------------
Have you had: (Circle)
| Yes No Burning or pain when urinating? | Yes No Loss of control of bladder? |
| Yes No Blood in urine? | Yes No Very dark colored urine? |
| Yes No Venereal disease? | Yes No Trouble starting to urinate? |
| Yes No Trouble holding the urine? | Yes No Getting up frequently at night? |
| Yes No Daytime frequency? | Yes No A kidney stone? |
-----------------------------------------------------------------------------------------------------------------------------
Have you recently had: (Circle)
| Yes No Pains in calves of legs when walking? | Yes No Cramps in legs at night? |
| Yes No Painfully swollen, hot or red joints? | Yes No Frequently stiff joints or muscles? |
| Yes No Back trouble interfering with normal activity? | Yes No Varicose veins? |
| Yes No Phlebitis or inflamed leg veins? | Yes No Swelling of the ankles? |
-----------------------------------------------------------------------------------------------------------------------------
Have you recently: (Circle)
| Yes No Been drinking large quantities of water? | Yes No Noticed unusual darkening of your skin? |
| Yes No Noticed change in tolerance to heat or cold? | Yes No Had increasing hairiness or hair loss? |
| Yes No Had excessively oily or dry skin (other than scalp)? |
-----------------------------------------------------------------------------------------------------------------------------
| Yes No Do you often have complete fatigue or exhaustion? | Yes No Does working tire you out completely? |
| Yes No Feel tired in the morning? | Yes No Ever have a nervous breakdown? |
| Yes No Do you prefer being alone? | Yes No Do you feel "blue" more than you feel happy? |
| Yes No Do you often feel uncomfortably nervous? | Yes No Do you feel life is not worth living? |
-----------------------------------------------------------------------------------------------------------------------------
Have you ever had: (Circle)
| Yes No Loss or decrease of sexual activity? | Yes No Swelling or pain of genitals (private parts)? |
| Yes No Treatment of genitals? | Yes No Sore on the genitals? |
-----------------------------------------------------------------------------------------------------------------------------
To be answered by men only:
| Yes No Discharge from penis? | Yes No Hemia (rupture)? |
| Yes No Prostate trouble? |
Describe BRIEFLY your present medical symptoms:
_________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________