Patient Forms

Infectious Disesases Patient History

 

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?
 
 
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 major childhood illnesses, place of service and date.
Please list any chronic conditions or serious illnesses, place of service and date.
 
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 all current immunizations.
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.
Have you had exposure to toxic or dangerous materials? Yes    No 
If yes, when?
What states have you visited in the past 2 years?
What countries have you visited in the past 2 years?
 
 
.

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 1
Any Major Health conditions or concerns?
Date and Cause of Death
 
Sibling 2
Any Major Health conditions or concerns?
Date and Cause of Death
 
Sibling 3
Any Major Health conditions or concerns?
Date and Cause of Death
 
 
Please list any 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.
 
Do you have pets? Please list type and quantity.
 
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.

 
Weight change (planned or unplanned) Yes    No 
Convulsions or Seizures Yes    No 
Frequent Headaches Yes    No 
Dizziness and/or Unsteadiness on your feet Yes    No 
Fainting Yes    No 
Do you wear glasses or contacts? Yes    No 
Change in Hearing Yes    No 
Sinus Issues Yes    No 
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? Yes    No 
Do you have a heart murmur? Yes    No 
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 
Swelling of feet or ankles? Yes    No 
Frequent Cough Yes    No 
Coughing up Blood Yes    No 
Bronchitis Yes    No 
Pneumonia Yes    No 
Pleurisy Yes    No 
Asthma or Wheezing Yes    No 
Emphysema Yes    No 
Abdominal Pain Yes    No 
Frequent Nausea Yes    No 
Vomiting Blood Yes    No 
Bloody or Black Stools Yes    No 
Frequent Diarrhea Yes    No 
Frequent Constipation Yes    No 
Hepatitis or Jaundice Yes    No 
Cirrhosis of Liver Yes    No 
Pancreatitis Yes    No 
Difficulty or Pain during Urination Yes    No 
Blood in Urine Yes    No 
Diabetes Yes    No 
Thyroid Problem Yes    No 
Cancer (any type) Yes    No 
Blood Disorder Yes    No 
Fever or chills Yes    No 
 
 
 
Please comment on any 'Yes' answers above.
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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