MEDICAL HISTORY FORM (for Adults > 17 years old)

Mark D. Freedman, MD

Name ______Birth date ____/____/______

Where were you born? ______How long have you lived in the Chicago area? ______Married Single Divorced Widowed

Who lives with you in your home? (list all) ______

Where do you work? ______Occupation ______

What is the main reason for this visit? ______

How were you referred to Dr. Freedman? ______

PAST HISTORY

Any unusual or severe childhood diseases? ______

Any surgeries / operations ?(please give date and place)______

______

______

Any bad accidents / broken bones? ______

______

Hospitalized for any illnesses? (please give date and place)______

______

______

Pregnant in past? HOW MANY PREGNANCIES? ______NORMAL DELIVERIES? ______CESAREAN DELIVERIES?_____

MISCARRIAGES or ABORTIONS? ______MEDICAL PROBLEMS with PREGNANCIES? ______

Taking any prescribed medications? ______

______

Any over-the-counter medications or supplements? ______

______

Allergic to any medications? ______

Allergic to any other substances? ______

Last visit to a doctor WHEN? ______WHO? ______

REASON______

LAST PAP SMEAR ______RESULTS______

LAST MAMMOGRAM ______RESULTS ______

LAST CHOLESTEROL TEST ______RESULTS ______

LAST COLONOSCOPY ______RESULTS ______

CARDIAC STRESS TEST ______RESULTS ______

CURRENT STATUS

Have you gained or lost a lot of weight in the past year? □ yes □ no How much? ______

Are you following any special diet? (explain)______How is your appetite?______

Do you exercise or play sports? □ Always, ____ times per week

What do you do or play? ______□ Occasionally, _____ times per month

□ Never

Any problems with your bowels? ______

Any problems with urination? ______

Are you sexually active? _____ □Homosexual □Heterosexual How many partners in the last year? _____

Any problems with sexual function? ______

Any sexually-transmitted diseases in the past? ______

Do you use any form of contraception or protection? ______Are you menstruating regularly? □YES □NO How often? □every 21-25 days □26-35 days □> 35 days

When was the first day of your last menstrual period? ______

Have you felt depressed in the last month? □YES □NO Been treated for depression in the past? □YES □NO

Do you smoke tobacco? □YES □ used to (date you quit ______) How much?______□NO

Drink alcohol? □YES How much? ______[beer] [wine] [other] □NO

Use marijuana?□YES How much? ______□NO Cocaine? □YES How much? ______□NO

Any other drugs? □YES Which ones? ______How much? ______□NO

PLEASE COMPLETE OTHER SIDE

FAMILY HISTORY

Please indicate the current status of your family members:

Alive Deceased Age (now or at death) State of health (or cause of death)

Mother ______

Father ______

Sister(s) [#_____] ______

Brother(s) [#_____] ______

Daughter(s) [#_____] ______

Son(s) [#_____] ______

Grandparents [#_____] ______

Grandchildren [#_____] ______

Please indicate with a check (√ ) family members who have had any of the following conditions:

Diseases / Mom / Dad / Sis / Bro / Husb/Wife / Mom's Mom / Mom's Dad / Mom's Sis / Mom's Bro / Dad's Mom / Dad's Dad / Dad's Sis / Dad's Bro / Child
ALCOHOL / DRUG ABUSE
ARTHRITIS
ASTHMA / ALLERGIES
BIRTH DEFECTS
BLEEDING PROBLEMS
BREAST / OVARIAN CANCER
COLON CANCER
OTHER CANCER
DEPRESSION
DIABETES
HEART DISEASE
HIGH BLOOD PRESSURE
MELANOMA (SKIN CANCER)
OSTEOPOROSIS
STROKE

ATTESTATION:

I, ______, attest that I have, to the best of my ability, provided accurate information in this medical history, and I understand that this history will be part of my medical record.

SIGNED ______Date ______

REVIEWED BY ______Date ______