Blue Ridge Endocrinology and Diabetes, PLC

Susan K. Blank, MD Margaret K. Crook, MD

199 Spotnap Road, Charlottesville, VA 22911
Phone: 434-293-7811 Fax: 434-293-7818

NEWPATIENTHEALTHHISTORYFORM
Name(Last,First,Middle):___________________________________
ReferringPhysicianName/Address:
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Age:__________DOB:________________

PrimaryCareProviderName/Address(ifnotreferring):
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Pleaselistthereason(s)youarecomingtotheclinic.
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Pleaseleaveblankforphysiciannotes.

PASTMEDICALHISTORY
Pleasecheckifyouhaveeverhadanyofthefollowingconditions.
Diabetes
COPD/Emphysema
Highbloodpressure
Asthma
Highcholesterol
Liverdisease
Angina
KidneyDisease
HeartAttack
KidneyStones
HeartFailure
StomachUlcers
Irregularheartrhythm
Heartburn
Stroke
PCOS
Thyroiddisease
AdrenalDisease
Osteoporosis/Osteopenia
PituitaryDisease
Cancer
Anxiety/Depression
Type_________________

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PhysicianNotes.

Pleaselistanyothermedicalproblems.
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Pleaselistallsurgeriesandyearwhentookplace.
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Forwomenonly:
Howoldwereyouwhenyouhadyourfirstmenstrualcycle?
Whatwasthedateofyourlastmenstrualcycle?
Howmanyperiodsdoyouhaveayear?
Haveyougonethroughmenopause?
Ifyes,atwhatage?
Howmanytimeshaveyoubeenpregnant?
Howmanychildrendoyouhave?
Howmanymiscarriageshaveyouhad?
Doyoucurrentlyuseamethodtopreventpregnancy?
Ifyes,whatmethod?
ALLERGIES/BADREACTIONS
Drug

______________
______________
______________
Yes
No
______________
______________
______________
______________
Yes
No
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Reaction

MEDICATIONS.Pleaselistallprescriptionmedications,overthecountermedications,
vitamins,andherbalsupplements.
Drug
Dose
Frequency
(i.e.10mg,units,etc.)

(numberoftimesaday)

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PhysicanNotes.

FAMILYHISTORY
Doyouhaverelativeswithanyofthefollowingconditions?
Yes
No
Relationtoyou(mother,sister,etc.)
Diabetes
Highbloodpressure
Highcholesterol
Heartdisease
Stroke
Thyroiddisease
Osteoporosis
Kidneystones
Calciumdisorder
Pituitarydisease
Cancer
Pleaselistspecifictypesofcancerandanyothersignificantmedicalconditions
inthefamilynotlistedabove.
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SOCIALHISTORY
Whatisyourmaritalstatus?
Single
Married
Divorced
Separated
Widowed
Inrelationship
Doyouhaveanychildren?
Yes
Ages____________________________
No
Whatisyouroccupation?_____________________________
Doyouexerciseregularly?
Yes
Typeofexercise?________________________
Howmanytimesaweek?__________________
No
Doyousmokecigarettes?
Yes
Numberofpacksaday?__________
Numberofyearsyouhavebeensmoking?__________
Notcurrently,butIsmokedinthepast
Quitdate?___________
Numberofpacksaday?__________
Numberofyearsyousmoked?___________
No,Ihaveneversmoked.
Doyoudrinkalcohol?
Yes
Numberofdrinksaweek?__________
Typeofalcohol?__________
No
Doyouuseanyrecreationalorstreetdrugs?
Yes
Notcurrently,butinthepast
Quitdate?___________
No
Haveyouevergivenyourselfstreetdrugswithaneedle?__________

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PhysicianNotes

SYMPTOMS
Haveyouhadanyofthefollowingsymptomsonaregularbasis?
Fever
Weightloss
Weightgain
Fatigue
Excessivethirst
Feelingexcessivelyhot
Feelingexcessivelycold
Excessivesweating
Lightheadedness

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No

Blurredvision
Doublevision
Tunnelvision
Bulgingeyes
Eyepain

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Dentalproblems
Hoarseness
Neckswelling/goiter
Swollenglandsinneck
Chokingsensations

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Cough
Wheezing
Shortnessofbreath

Yes
Yes
Yes

No
No
No

Chestpain
Heartracing/palpitations
Legswelling

Yes
Yes
Yes

No
No
No

Breasttenderness
Fluidleakagefrombreast
Breastlump

Yes
Yes
Yes

No
No
No

Excessiveurination
Wakingupatnighttourinate
Weakurinestream

Yes
Yes
Yes

No
No
No

Abdominalpain
Heartburn
Nausea
Vomiting
Diarrhea
Constipation

Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No

Headaches
Tremors
Numbness/Tingling

Yes
Yes
Yes

No
No
No

Jointaches
Muscleaches
Lossofheight
Backpain
Changeinringsize
Changeinshoesize

Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No

Rash
Dryskin
Hairloss
Excessivehairgrowth
Acne

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Easybruising/bleeding

Yes

No

Depressedmood
Excessivenervousness

Yes
Yes

No
No

Forwomenonly:
Irregularmenstrualcycle
Unusualvaginalbleeding
Hotflashes
Lowsexualdesire

Yes
Yes
Yes
Yes

No
No
No
No

Formenonly:
Difficultywitherections
Lowsexualdesire

Yes
Yes

No
No

PhysicianNotes.

_________________________________________________
PatientSignature
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Date