You miss 100% of the shots you don’t take. Wayne Gretzky
Idea Transcript
Name:______________________________
Date:_________________________
Birthdate:___________________________
Age:__________________________
REASONS YOU ARE SEEING THE DOCTOR:___________________________________________ SYMPTOMS Use “C” for current and “P” for previous. BE SURE TO CHECK ALL THAT APPLY GENERAL
MISCELLANEOUS/JOINT/BONE
CARDIOVASCULAR
SKIN
___Depression
___Joint Replacement
___Chest Pain
___Bruise Easily
___Dizziness
___Pain
___High Blood Pressure
___Change in Moles
___Fever
___Surgery
___Irregular Heartbeat
___Cold Sores, Fever
___Headaches
___Weakness
___Low Blood Pressure
___Blisters
___Loss of Weight
___Pacemaker
___Hives
___Nervousness
___Poor Circulation
___Infection
___Sweats
GASTOINTESTINAL
___Shortness of Breath
___Rash
___Fainting
___Appetite Change
___Swelling of Ankles
___Scars/Keloids
___Bowel Change
___Trouble Clotting
___Sore Not Healing
___Varicose Veins
___Eczema ___Psoriasis
GENITO-URINARY ___Painful Urination
EARS/NOSE/THROAT ___Hay Fever
MEN ONLY ___Sores on Penis
___Skin Cancer If yes, which: ___Basal Cell Carcinoma
___Nosebleeds ___Squamous Cell ___Melanoma ___Other, specify Please explain any positive response below CONDITIONS Use “C” for current and “P for previous ___AIDS
___Chemical Dependency
___Hepatitis
___Moles Removed
___Alcoholism
___Chicken Pox
___Herpes
___Mononucleosis
___Anemia
___Diabetes
___High Cholesterol
___Multiple Sclerosis
___Anorexia
___Emphysema
___HIV Positive
___Rheumatic Fever
___Arthritis
___Epilepsy
___Hormone Problem
___Stroke
___Asthma
___Glaucoma
___Joint Replacement
___Thyroid Problems
___Bleeding Disorders
___Goiter
___Kidney Disease
___Tuberculosis
___Breast Lump
___Gout
___Liver Disease
___Typhoid Fever
___Bulimia
___Hay Fever
___Melanoma
___Ulcers
___Cancer
___Heart Disease
___Migraine Headaches
___Other
___Heart Murmur
___Mitral Valve Prolapse
Please Explain:_________________________________________________________________________________ _____________________________________________________________________________________________ MEDICATIONS – List Type, Dosage and Duration TYPE
DOSAGE
DURATION
ALLERGIES – Drug Allergies and Reaction Anesthesia
Aspirin
Codeine
Erythromycin
Penicillin
Sulfa
Tetracycline
Lidocaine
Novocain
Other
NON DRUG ALLERGIES:
___Food
___Latex
___Tape
____Anesthetic
SURGERIES – Previous Surgeries/Dates and all Hospitalizations SURGERY/HOSPITALIZATION
FAMILY HISTORY: Mother:
Father:
___Other
DATE
Number of Children: ______ Ages:____________________
Please check the following medical conditions that have occurred in your family DISEASE Allergies Arthritis Asthma Cancer Diabetes Eczema Hay Fever
SOCIAL HISTORY: Please check all that apply Do you smoke? _____ Frequency _____________ Do you use recreational drugs? ______ Frequency __________ Do you drink alcohol? ______ Frequency ______________ Hobbies: ____________________________________ HEALTH HISTORY QUESTIONS: Have you been advised to take antibiotics before any surgery or dental work? If yes, what is the reason?__________________________________________ Do you take blood thinners, anticoagulants or aspirin? If yes, which ones? _______________________________________________ Do you take tranquilizers or sedatives? If yes, which ones?_______________________________________________ Are you currently taking insulin? Are you currently taking antibiotics? If yes, which ones? ______________________________________________ Are you currently taking birth control pills? Are you currently pregnant or plan to become pregnant in the near future? Are you currently taking vitamins? If yes, which ones?______________________________________________ Did you ever take cortisone either by moth or injections? Have you ever had a blood transfusion? If yes, reason and date __________________________________________ Have you ever been examined by a Dermatologist? If yes, for what condition? _______________________________________ Have you ever been treated for the same condition for which you are being seen today? If yes, please list the doctors’ names and addresses ___________________ Do you or anyone in your family form excessive scar tissue? Are you currently applying hydrocortisone, cortisone or any other medication to your skin? Is there any other information that you fee is important for the doctor to know when Evaluating your medical condition? ___________________________________________
____Yes ____No ____Yes ____No ____Yes ____No ____ Yes ____No _____Yes ____No _____Yes ____No _____ Yes ___No _____ Yes ____No _____ Yes ____No _____ Yes ___ No _____ Yes ___ No _____ Yes ___ No _____ Yes ___ No _____ Yes ___ No _____ Yes ___No
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of this staff responsible for any errors or omissions that I may have made in the completion of this form Signature:_________________________________
Date:____________________________________
**I have reviewed this Patient History Form with the patient:__________________________Date:_____________