Patient History Form - Free Download | Page 3
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Patient History Form Page 3
Medical History Form 3
CURRENT Patient Symptoms
Please indicate (X) CURRENT SYMPTOMS
(please PROVIDE DETAILS for all "YES" answers in space provided):
HEAD / NECK Headache Migraine Describe:
Concussion Head
Injury
Describe:
Seizures Dizzy spells Details:
Fainting Light
Headedness
Details:
Loss of Memory Details:
Visual problems: Glasses Contacts Details:
Blind in either eye: Right Left Etiology / cause:
Color blind Double Vision Details:
Hearing Difficulties: Loss Ringing / tinnitus Details:
Hearing Aid: Right Left Details:
Environmental allergies Skin Allergies Describe:
Sinus congestion Allergy related symptoms Describe:
Mouth: Poor Teeth Toothaches Describe:
Bleeding Gums Mouth Sores Describe:
Oral Hot / Cold Intolerance Etiology / cause:
CHEST Chest Pain / Discomfort Palpitations Describe:
Shortness of Breath - At rest With exercise Describe:
Cough Cough up blood Details:
Wheeze Associated with activity What activity
Breast lump or pain Nipple discharge Details:
THROAT Swollen Glands Difficulty Swallowing Details:
GASTROINTESTINAL Nausea Vomiting Etiology:
Diarrhea Constipation Frequency:
Change in Bowel Habits Longer than 1 week Details:
Abdominal Pain Hernia Describe:
Hemorrhoids - Internal Hemorrhoids - External Details:
Bloody or tarry stools Frequency: Associated with hard stools
URINARY Burning with urination Frequency of urination Frequency:
Urinary Incontinence Difficulty starting stream Frequency:
Increased urination at night Inability to empty bladder Frequency:
MUSCULOSKELETAL Muscle / joint pain Muscle / joint stiffness Location:
Fracture or broken bone Limitation in motion Location:
Numbness or Tingling Weakness Location:
SKIN Rash Mole / Skin Lesion Location:
Bruise / Bleed easily Unexplained Lumps Location:
OTHER Unexplained weight loss Unexplained weight gain Number of pounds:
Excessive thirst Night sweats Frequency:
Change in energy level Weakness Details:
Fever / chills Mood swings Describe:
Anxiety Depression Describe:
Insomnia - can't fall asleep Inability to stay asleep Treatment:
Snoring Does snoring wake you Frequency:
Daytime sleepiness Are you told you stop breathing for periods of time when asleep
Are you sexually active
Method of Birth Control:
Sexual Concerns:
FEMALES:
This information is accurate and complete to the best of my knowledge.
Patient Signature:
Reviewer Name and Signature: ______________________________________________________________________________
page 2
Patient Name:
Y N
Date:
Date of last menstrual period:
Unusual vaginal bleeding
Y N
Are you pregnant
Y N
Please provide any other information you feel your physician should be aware of:
NY
Prostate Problems
MALES:
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