Patient History

Name:
Address:
State/Provence:
Zip/Postal Code:
Phone:
Cell Phone:
Birthdate:
Email:
Education:
Maritial Status:
Medical Insurance Policy Number:
Social Security Number:
Date of Last Physical Exam (annual exam):
Date of Last Mammogram:
Date of Last Lab Evaluation:
Health status of Relatives (father, mother, sister, brother, etc.):
Family Risk
(Any heart disease, cancer, high blood pressure, suicide, diabetes, mental illness, stroke, epilepsy):
Menstrual Cycle Histoy:
Pregnancies:
Birth Control:
Last Pelvic Exam:
Troubling Symptoms:
Sexual History (including any difficulties with libido and exposures to STD's):
Please Explain If You Experienced These Symptoms and/or Conditions:

Allergies to medications and other items (antibiotics adhesives, latex, aspirin codeine, lidocaine, etc)

Anemia, Arthritis, Cancer, Chicken Pox, Cold hands and feet, Constipation, Diarrhea, Diphtheria, Epilepsy, Fatigue, Food , chemical and /or environmental allergies, Gallbladder Disease, German Measles, Heart Disease, High blood pressure, Hospitalizations, Influenza, Injuries (Broken bones, sprains, dislocations, head injury, lacerations, etc), Measles, Migraine Headaches, Mumps, Pleurisy, Pneumonia, Rheumatic Fever, Scarlet Fever, Sciatica or any other musculoskeletal problem, Sexually Transmitted Disease (Syphilis, Gonorrhea, HIV), Smallpox, Stroke
Please Explain If You Experienced These Symptoms and/or Conditions:

Surgeries, Transfusions, Urinary Bladder Disease, Weight (Current, Highest and lowest), Whooping Cough
Check All That Apply:
Frequent or severe headaches
 Fainting spells
Dizziness on change of position
Unconscious spells
Blurred Vision
Double Vision
Spots before eyes
Infected eyes
Change in vision
Do you wear corrective lenses or contacts
Earaches or infections
Ringing in ears
Hearing loss
Nose bleeds
Head colds
Sinus trouble
Hay fever and allergies
Loss of taste or smell
Strange body odors or breath
Difficulty swallowing
Persistent hoarseness
Cough or coughing up blood
Shortness of breath
Chest pain
Poor circulation / purple fingers of toes
Enlarged veins
Prolonged bleeding
High blood pressure
Indigestion
Acid reflux
Poor appetite
Vomiting blood
Blood in stool
 Frequent diarrhea and / or constipation
Abdominal cramping
Pain on urination
Blood in urine
Rectal Pain
Discharge from genitalia (Vagina or Penis)
Swelling of joints
Fluid retention
Brittle nails
Tingling in hand and feet
Dryness of skin
Depression
Decreased memory
Fatigue
Back pain
Hair loss
Inability to stand cold or heat
Memory loss
Decreased sex drive
Increased menstrual bleeding
Increased clotting during period
Hot flashes
Easy bruising
Skin rash and or other growths

Any other condition or symptom of concern:
Please List Any Other Relevant Information Concerning Your Current Health Concerns:



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