Patient Forms

Endocrinology Patient History

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Demographic Info

 
First Name
Last Name
Phone Number
Date of Birth
 
Reason for Consultation and History of Present Illness
Please list any recent medical testing, place of service and results, if known.
Please list all past surgeries, place of service and date.
Please list all hospitalizations, place of service and date.
Please list any current or past significant medical conditions. Ex: hypertension, diabetes, pneumonia, car accident, fractures, etc.
 
Have you had a blood transfusion? Yes    No 
If yes, when?
 
 
 

Current Snapshot

 
Please list all current medications, vitamins and supplements. Include dose, frequency, and start date for each.
Please list any medication allergies and explain symptoms.
Please list any food or other allergies and explain symptoms.
 
 
 

>Social History

 
What is your highest level of education?
What is your current occupation?
Describe your current occupation.

Family History

 
Father
Any Major Health conditions or concerns?
Date and Cause of Death
 
 
Mother
Any Major Health conditions or concerns?
Date and Cause of Death
 
 
Sibling(s)
Any Major Health conditions or concerns?
Date and Cause of Death
 
Please list any other Blood Relatives with Major Health conditions or concerns. Include relationship and problem.
 
 

Everyday Life

 
Current Marital Status
Please list gender and age of any children.
 
How many meals per day do you eat?
How many snacks per day do you eat?
 
How many hours do you typically sleep each night?
Do you feel you typically get enough sleep? Yes    No 
Please tell us about your exercise habits.
 
 
Smoking History
Have you ever smoked regularly?
How many years?
How many packs a day?
When did you stop?
 
Coffee History
Do you drink coffee regularly?
How many years?
How many cups per day?
When did you stop?
 
Alcohol History
Have you ever consumed alcohol regularly?
How many years?
How many drinks a week?
When did you stop?
 
Street Drug History
Have you ever used drugs regularly?
What drugs?
How long?
When did you stop?
 
 

Review of Systems: Mark Yes for any item experienced in the past 2 years.

 
General/Constitutional
 
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 
 
Please comment on any 'Yes' answers from this section.
 
Eyes
 
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 
 
Please comment on any 'Yes' answers from this section.
 
HENT
 
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 
 
Please comment on any 'Yes' answers from this section.
 
Neck
 
Neck Pain Yes    No 
Neck Mass Yes    No 
Swollen Lymph Nodes Yes    No 
 
Please comment on any 'Yes' answers from this section.
 
Cardiovascular
 
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 
 
Please comment on any 'Yes' answers from this section.
 
Chest/Lungs
 
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 
 
Please comment on any 'Yes' answers from this section.
 
Gastrointestinal
 
Nausea Yes    No 
Heartburn Yes    No 
Vomiting Yes    No 
Diarrhea Yes    No 
Constipation Yes    No 
Pancreatitis Yes    No 
 
Please comment on any 'Yes' answers from this section.
 
Genitourinary
 
Frequent Urination Yes    No 
Night Time Urination Yes    No 
Blood in Urine Yes    No 
Kidney Problems Yes    No 
Kidney Stones Yes    No 
 
Please comment on any 'Yes' answers from this section.
 
Musculoskeletal/Skin
 
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 
 
Please comment on any 'Yes' answers from this section.
 
Neurological
 
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 
 
Please comment on any 'Yes' answers from this section.
 
Psychological
 
Anxiety Yes    No 
Depression Yes    No 
History of Mental Illness Yes    No 
Lithium Use Yes    No 
 
Please comment on any 'Yes' answers from this section.
 
Endocrine
 
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.
 
 
 
 
Other
Please describe any other medical issues or concerns you have today.
Do you need your records sent to another office? If so, where?
Do you need your records requested from another office? If so, where?
 
 
 
 

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