Health Information Form Established Pts

Name: _____________________________ A. Please Tell Us What Brings You Here Today

1. Condition(s): ____________________________________________________________________________________________ 2. How long ago did the problem(s) start? ____________________________________________________________________________________________ 3. Did you remember anything happening before the problem(s) started? ____________________________________________________________________________________________ 4. What treatments have you tried for the problem(s) (if any)? ____________________________________________________________________________________________ If you have pain: 1. Where is the pain located? _________________________________________________________ 2. On a scale of 1 to 10, how bad is the pain? __________________________________________ 3. What does the pain feel like (sharp, throbbing, burning, etc.)_________________________ 4. Does the pain radiate anywhere? __________________________________________________ 5. Is the pain constant or does it come and go? ________________________________________ 6. If it comes and goes, how many times a day does it happen? ________________________ 7. If it comes and goes, how long does the pain last? __________________________________ 8. What makes the pain worse (e.g., walking, lying down)? _____________________________

Health Information Form Established Pts

9. What makes the pain better? _______________________________________________________ 10. What treatments have you tried for the pain? _______________________________________ 11. Is the pain associated with any other symptoms? ____________________________________

Health Information Form Established Pts

B. Review of Systems

Health Information Form Established Pts

1. General
fever chills skin cancer itching rash

2. Eyes
eye pain light sensitivity

10. Nervous System

poor balance headaches falling down seizures tremors fainting

3. Ears, Nose, Throat

earache nasal congestion hoarseness sore throat

4. Heart
chest pain racing/skipping heart beats lightheadedness difficulty breathing when you lie down fainting

11. Mental Health

sense of great danger (panic attacks) anxiety thoughts of suicide depression thoughts of violence frightening visions or sounds excessive anger

5. Lungs
cough shortness of breath wheezing snoring

12. Endocrine
cold intolerance heat intolerance excessive urination excessive thirst

6. Bowels
indigestion/heartburn/reflux nausea vomiting abdominal (belly) pain diarrhea

13. Blood System

swollen glands unusal bleeding abnormal bruising fevers

7. Urinary System
inability to empty bladder difficulty holding urine trouble starting stream painful urination

14. Allergies
persistent infections seasonal allergies HIV exposure Problems not listed above: ________________________________________________

8. Musculoskeletal
joint pain joint swelling muscle weakness gout

9. Skin
suspicious areas

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C. Allergies/Drug Sensitivities
Allergy/Sensitivity Type
(include medications foods environmental or other)

Reaction

Date last Occurred

Treatment

D. Medication Changes (additions or deletions)

Note: Include all prescription medications, (such as nitroglycerin) over-the-counter medications (taken on a regular basis), vitamin supplements, and herbal remedies

Medication / Dosage

Frequency

E. Lifestyle
Alcohol Smoking Exercise Drink(s) Per Week: Pack(s) Per Day: Type(s) of Exercise: Number of Years: Number of Years: Days Per Week:

F. Any other information your doctor should know:

Health Information Form Established Pts