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Patient History |
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First Name |
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Last Name |
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Phone Number |
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Date of Birth |
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Reason for Consultation and History of Present Illness |
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Please list any recent medical testing, place of service and results, if known. |
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Please list all past surgeries, place of service and date. |
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Please list all hospitalizations, place of service and date. |
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Please list any current or past significant medical conditions. Ex: hypertension, diabetes, pneumonia, car accident, fractures, etc. |
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Have you had a blood transfusion? |
Yes
No |
If yes, when? |
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Current Patient Info |
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Please list all current medications, vitamins and supplements. Include dose, frequency, and start date for each. |
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Please list any medication allergies and explain symptoms. |
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Please list any food or other allergies and explain symptoms. |
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Do you have a Medical Power of Attorney? Please bring a copy to your first appointment. |
Yes
No |
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Do you have a Durable Power of Attorney? Please bring a copy to your first appointment. |
Yes
No |
Do you have a Living Will? Please bring a copy to your first appointment. |
Yes
No |
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Social History |
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What is your highest level of education? |
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What is your current occupation? |
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Describe your current occupation. |
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Family History |
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Father |
Any Major Health conditions or concerns? |
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Date and Cause of Death |
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Mother |
Any Major Health conditions or concerns? |
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Date and Cause of Death |
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Sibling(s) |
Any Major Health conditions or concerns? |
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Date and Cause of Death |
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Please list any other Blood Relatives with Major Health conditions or concerns. Include relationship and problem. |
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Everyday Life |
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Current Marital Status |
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Please list gender and age of any children. |
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How many meals per day do you eat? |
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How many snacks per day do you eat? |
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How many hours do you typically sleep each night? |
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Do you feel you typically get enough sleep? |
Yes
No |
Please tell us about your exercise habits. |
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Smoking History |
Have you ever smoked regularly? |
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How many years? |
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How many packs a day? |
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When did you stop? |
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Coffee History |
Do you drink coffee regularly? |
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How many years? |
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How many cups per day? |
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When did you stop? |
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Alcohol History |
Have you ever consumed alcohol regularly? |
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How many years? |
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How many drinks a week? |
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When did you stop? |
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Street Drug History |
Have you ever used drugs regularly? |
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What drugs? |
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How long? |
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When did you stop? |
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Review of Systems: Mark Yes for any item experienced in the past 2 years. |
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General/Constitutional |
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Fatigue/Tiredness |
Yes
No |
Fever |
Yes
No |
Chills/Hotflashes |
Yes
No |
Loss of Appetite |
Yes
No |
Weight change (planned or unplanned) |
Yes
No |
Excessive Thirst |
Yes
No |
Change in Body Hair |
Yes
No |
Cancer (any type) |
Yes
No |
Decreased Libido |
Yes
No |
Erectile Disfunction |
Yes
No |
Sleep Issues |
Yes
No |
Abdominal Pain |
Yes
No |
Heat Intolerance |
Yes
No |
Cold Intolerance |
Yes
No |
Bone Pain |
Yes
No |
Back Pain |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Eyes |
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Do you wear glasses or contacts? |
Yes
No |
Blurry Vision |
Yes
No |
Double Vision |
Yes
No |
Blindness |
Yes
No |
Eye Pain or Swelling |
Yes
No |
Eyes that Buldge Out |
Yes
No |
Photophobia |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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HENT |
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Difficulty Swallowing |
Yes
No |
Hoarseness/Voice Changes |
Yes
No |
Change in Hearing |
Yes
No |
Ringing in Ears |
Yes
No |
Hearing Impairment |
Yes
No |
Headache |
Yes
No |
Lightheadedness on Change of Position |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Neck |
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Neck Pain |
Yes
No |
Neck Mass |
Yes
No |
Swollen Lymph Nodes |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Cardiovascular |
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High Blood Pressure |
Yes
No |
Chest Pain at rest |
Yes
No |
Chest Pain during exercise |
Yes
No |
Does your heart ever race or skip beats (palpatations)? |
Yes
No |
Blood Clots |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Chest/Lungs |
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Are you short of breath while exercising? |
Yes
No |
Are you short of breath at night? |
Yes
No |
Are you short of breath at rest? |
Yes
No |
Chronic Cough |
Yes
No |
Asthma or Wheezing |
Yes
No |
Snoring |
Yes
No |
Breast Pain |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Gastrointestinal |
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Nausea |
Yes
No |
Heartburn |
Yes
No |
Vomiting |
Yes
No |
Diarrhea |
Yes
No |
Constipation |
Yes
No |
Pancreatitis |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Genitourinary |
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Frequent Urination |
Yes
No |
Night Time Urination |
Yes
No |
Blood in Urine |
Yes
No |
Kidney Problems |
Yes
No |
Kidney Stones |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Musculoskeletal/Skin |
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Swelling of joints? |
Yes
No |
Joint Pain |
Yes
No |
Bone Fractures |
Yes
No |
Muscle Weakness |
Yes
No |
Muscle Cramps |
Yes
No |
Swollen Legs |
Yes
No |
Skin Lesions/Sores |
Yes
No |
Itching |
Yes
No |
Rashes |
Yes
No |
Bruising |
Yes
No |
Color Changes of elbow/neck |
Yes
No |
Acne |
Yes
No |
New Stretch Marks |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Neurological |
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Dizziness and/or Unsteadiness on your feet |
Yes
No |
Fainting |
Yes
No |
Convulsions or Seizures |
Yes
No |
Loss of Sensation |
Yes
No |
Tingling/Numbness |
Yes
No |
Trembling Hands |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Psychological |
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Anxiety |
Yes
No |
Depression |
Yes
No |
History of Mental Illness |
Yes
No |
Lithium Use |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Endocrine |
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Nipple Discharge/Milk Production |
Yes
No |
Diabetes |
Yes
No |
Thyroid Problem |
Yes
No |
Blood Disorder |
Yes
No |
Recent Change in Height |
Yes
No |
Increase in Ring or Shoe Size |
Yes
No |
PCOS |
Yes
No |
Irregular Periods |
Yes
No |
No Periods |
Yes
No |
Infertility |
Yes
No |
Please comment on any 'Yes' answers from this section. |
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Other |
Please describe any other medical issues or concerns you have today. |
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Do you need your records sent to another office? If so, where? |
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Do you need your records requested from another office? If so, where? |
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Click Here to Submit Form |
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