Fred Bloem, M.D.
4108 Alfalfa Terrace – Olney, MD 20832-2962
Phone: 301-260-2601 – Fax: 240-206-2740
www.drbloem.com – Directions: www.drbloem.com/directions.htm
Instructions for Completion of Patient Medical History for Adults
Please complete this form with as much detail as you can. If symptoms or items do not apply to you, please leave them blank. You may use the following abbreviations: Y=Yes, nl=normal, abnl=abnormal.
Please bring any copies of laboratory test results if available. Don’t be concerned about missing or incomplete information as we can fill in the blanks or obtain missing data later.
Please bring any other relevant items, such as medications, supplements, etc.
There are two ways to complete this form:
1. Electronically (preferred)
Complete the information on your computer. It is easy to double click on the red lines and type. You may then e-mail the file to me or take it to my office on a CD, a USB flash drive or other portable medium. You may also print a copy of the completed form.
2. Handwritten
Please print this form and write in your personal information and/or use a separate sheet if you need more space. When using separate sheets, please use numbers to correlate your information with the items on this form.
Please understand that when you e-mail or fax this form ahead of time, that Dr. Bloem does not typically review the medical history form before he meets with you. This form will be reviewed in your presence to allow you to elaborate on any information that requires clarification.
Please complete this form with as much detail as you can. Please indicate positive findings by 1) entering text, 2) entering Y(es), or 3) entering a number indicating severity on a scale of 1 to 10 (e.g., 1/10 is mild pain and 10/10 is intense pain). If the items do not apply to you simply leave the spaces blank.
1. General Patient Information
Full Name: First_Middle_Last
Date of birth: ___
Place of birth: ___
Address: Street_Apt_City_State_Zip
Phone (home): ___
Phone (work): ___
Phone (mobile): ___
Fax: ___
E-mail (work): ___
E-mail (personal): ___
Emergency contact (name of person): ___
Emergency contact (phone): ___
Pharmacy phone: ______Pharmacy fax: ______
How did you learn about Dr. Bloem? ___
2. Health Insurance
Health insurance company: ___
Name of primary policy holder: ___
Health insurance policy ID number: ___
Group Plan number: ___
Health insurance telephone number: ___
Other insurance related identifying information (e.g., RxBIN, RxPCN, RxGRP, Plan Number): ___
3. Healthcare Practitioners Consulted
Current primary care physician name/practice name, specialty, telephone number, and fax number: Name_Specialty_Phone_Fax
Dates of first visit and last visit: ___
Main reasons for seeing this physician (e.g., routine physicals, diabetes care): ___
Other healthcare practitioner name, specialty, telephone number, and fax number (copy this section as often as necessary if there are multiple practitioners that you have consulted with): Name_Specialty_Phone_Fax
Dates of first visit and last visit: ___
Main reasons for seeing this health practitioner: ___
4. Active Medical Problems
Please list your current medical problems, and describe the date of onset, how the diagnosis was made, treatments and response to these. Please list any emotional stresses or traumas that occurred prior to your illness or since. Example: 1970: Diabetes, diagnosed based on symptoms of fatigue and frequent urination and confirmed with high blood sugar levels. Used to be on oral medication but am now taking insulin.
Date_of_onset/diagnosis_Problem_Treatment_Response
___
5. Main Reasons for Seeking Help Now
Please explain why you are seeking help from me now (e.g., symptoms have worsened; symptoms have not responded to treatment; concern about long-term complications).
___
When was the last time you felt well?
___
6.1 Medications, Remedies, Nutritional Supplements
Please list all the prescription and nonprescription medications, remedies, and nutritional supplements that you are taking. Please list start date, the dose, the frequency, the brand/manufacturer, the prescribing physician or the person who recommended these, the reason why you are taking them, how well they are working, and whether or not you are experiencing any side effects. Example: 1990: Prozac 40 mg once daily, prescribed by Dr. Jones for depression. Used to be effective to alleviate depression initially but have found it to be less effective recently. Have experienced weight gain since starting this and am looking for an alternative solution.
Start_Date_Medication_Brand_Manufacturer_Dose_Frequency_Prescriber_Reason_Effectiveness_Side_effects?
___
Are you now using oral or injectable contraceptives or an IUD (intrauterine device)?
___
6.2 Past Medication History
Have you ever used any of the following medications? If so, how frequently and for what duration?
Oral contraceptives (birth control pills)? ___
IUD (intra-uterine contraceptive device)? ___
Depo Provera? ___
Premarin? ___
Provera? ___
Steroids (e.g., prednisone, cortisone shots) ___
Antibiotics? ___
Have you ever been a paid or volunteer participant in a medical research study? If so, please provide details of pharmaceutical and other exposures.
___
7. Allergies
Please list any allergies to medications, foods, or other allergens, and describe your reaction to these allergens.
___
Any allergies to wheat ___ , dairy ___ , others ___
Have you ever been tested for allergies? ___ Copies of reports? ___
Have you ever been treated for allergies? ___
8. Chemical Sensitivities
Do you have chemical sensitivities (e.g., perfume, cigarette smoke, paint, construction materials, carpet)? ___
9. Electromagnetic Sensitivities
Do you have electromagnetic sensitivities (e.g., computers, TVs, video screens, radios, fluorescent lights and “low-energy” light bulbs, cell phones and cordless phones, electric heaters and air conditioners, elevators and escalators, wireless devices such as microphones, headsets, and computer networks, transformers and power supplies, battery chargers, etc., battery back-up systems for computers (UPSs), surge suppressor power strips, amplifiers and speakers, dimmer switches, projectors, electric utility meters and distribution panels, inverters in solar-electric systems)? ___
10. Hospitalizations
Please list all the times you were hospitalized, the reasons for hospitalization, the treatments and outcome. Example: 1980: Pneumonia, hospitalized for 7 days, treated with antibiotics and had a full recovery.
Date_Reason_for_hospitalization_Treatment_Outcome
___
11. Surgeries or Medical Procedures
Please list all the times you had surgery or medical procedures.
Date_Surgical_procedure_Reason_Outcome_Complications?
___
Are any of your organs or body parts missing (e.g., gallbladder, appendix, tonsils, adenoids, ovaries, testicles, uterus, part of intestinal tract)? ___ If so, please provide details.
___
12. Past Medical Problems
Please list any health issues that have now resolved or that are dormant and that are not symptomatic now (e.g., childhood illnesses, sexually transmitted disease, other infectious or toxic exposures, accidents, major trauma, scars (please give location)). Example: 1980: recurrent ear infections during childhood and received multiple courses of antibiotics until age 10.
Start_date_Problem_Date_resolved
___
13. Education and Occupation
Please briefly describe your occupation and the activity you perform (start date, part-time/full-time?): ___
If you have a second job or occupation, please briefly describe it and the activity you perform (start date, part-time/full-time?): ___
What are the days and hours that you work? ___
Any occupational stresses or hazards (e.g., mental or physical stress, toxic exposures (mold, chemicals, etc.), repetitive motions, sick building syndrome)? ___
Previous occupations or work experiences: ___
Highest level of education: ___
14. Religion and Associated Customs
Religion: ___
Please describe any religious beliefs, customs, or practices with health implications (e.g., fasting, dietary customs): ___
Are spiritual issues important to you? ___
What do you do in the spiritual areas of your life? ___
15. Family
Marital status: ___
If married, length of current marriage: ___
If not married, have you previously been married? ___ How many times? ___ Length of each marriage? ___
Occupation of spouse or other adult(s) in family: ___
Names, ages, and relationship* of other people who are in your household. *E.g., husband, sister, brother, roommate.
Name_Age_Relationship*
___
16. Family History
Are there any diseases that are common in your blood relatives (grandparents, parents, and children)?
Please use the following abbreviations.
F=Father; PGF=Paternal grandfather; PGM=Paternal grandmother; FB=Father's brother; FS=Father's sister
M=Mother; MGF=Maternal grandfather; MGM=Maternal grandmother; MB=Mother's brother; MS=Mother's sister
B=Brother; SR=Sister; S=Your son; D=Your daughter.
Please number individuals in the same generation (e.g., S1 is your oldest son; MB2 is your mother's second oldest brother).
Please indicate age of onset, cause of death and age of death.
Diabetes ___ , hypertension ___ , heart attack ___ , stroke ___ , sudden death ___ , breast cancer ___ , colon cancer ___ , thyroid disease ___ , allergies ___ , asthma ___ , bleeding tendency ___ , epilepsy ___ , gallbladder ___ , glaucoma ___ , hearing loss ___ , hypoglycemia ___ , kidney disease ___ , liver disease ___ , lupus ___ , multiple sclerosis ___ , fatigue ___ , rheumatoid arthritis ___ , tuberculosis ___ , overweight/obesity ___ , mental illness ___ , depression ___ , alcohol abuse ___ , drug abuse ___ , other ___
17. Review of Systems
Please indicate if you have any of the following symptoms. Please describe the date of onset, the severity on a scale of 1 to 10 (most severe) or yes, as appropriate; whether the complaint is constant or whether it comes and goes; any contributing factors; things that make it worse and that make it better; as applicable, the location of the symptom or complaint. If symptoms or items do not apply to you, please leave them blank.
17.1 General
Cold intolerance ___ , cold hands and feet ___ , fatigue ___ , difficulty waking up in the morning ___ , feeling like you could take a nap any time ___ , fatigue in the afternoon ___ , difficult to recover after physical activity ___ , headache ___ , headaches in the morning ___ , headaches in the afternoon ___ , headaches with exertion or stress ___ , “splitting” type headaches ___ , fluid retention ___ , feeling jittery ___ , feeling shaky ___ , inward trembling ___ , hot flashes ___ , daytime sweats ___ , night sweats ___ , perspire easily ___ , always thirsty ___ , always hungry ___ , you look older than you are ___ , feet too hot at night ___
Does your face look thinner? ___
Insomnia ___ Time you go to bed, fall asleep and wake up: ___
Difficulty falling asleep ___ , waking up during the night ___ . Why? ___ Hard to fall asleep again? ___
Do you use a sleep aid? ___
How many hours of sleep do you require to function properly? ___
Is the room completely dark when you sleep (i.e., no lights on in the room; no light from street lamps coming through the windows)? ___
17.2.1 Weight and Height
Height: ___ Have you lost height? ___ Do you have vertebral fractures (compression fractures in the spine)? ___
Current weight and date weighed: ___
Is your waist girth equal or larger than hip girth? ___
Weight during childhood (normal, under/overweight) ___ , weight during adolescence ___ , weight during adulthood ___ , weight fluctuations ___ , weight gain ___ , weight loss ___ , abdominal weight gain ___ , weight gain when under stress ___ , difficulty gaining weight ___
Clothes size(s) ___
What causes you to lose or to gain weight (e.g., type of food, amount of food, emotional ties to food, stress, depression, food cravings, slow metabolism, lack of exercise)? ___
17.2.2 Developmental History
Any problems while you were in your mother’s womb? ___ , duration of gestation (number of weeks)? ___ , perinatal problems (around the time of your birth)? ___
While you were in womb, did your mother smoke cigarettes or use alcohol (including wine or beer), or any prescription drugs or street drugs? ___
Were you breast fed? ___ For how long? ___ Were you fed infant formula? ___ For how long? ___
Any problems with learning, attention, concentration, or dyslexia? ___
Any adverse reactions to childhood immunizations? ___
Any other developmental or childhood problems? ___
17.3 Mental Health
Depression ___ , anxiety ___ , obsessive compulsive behavior or thinking ___ , mania ___ , delusions ___ , feelings of paranoia ___ , memory problems ___ , trouble concentrating or focusing ___ , easily confused ___ , loss of interest or motivation ___ , easily agitated ___ , easily upset ___ , suicidal thoughts ___ , suicide attempts ___
17.4 Stress
Financial stress ___ , work related stress ___ , marital stress ___ , family related stress ___ , other stress ___
What activities do you perform to reduce stress? ___
How often do you perform these activities? ___
Do you believe stress is presently reducing the quality of your life? ___
Do you feel significantly less vital than you did one year ago? ___
Are you happy? ___
Do you feel your life has meaning and purpose? ___
Do you like the work you do? ___
Have you ever experienced major losses in your life? ___
Do you spend the majority of your time and money to fulfill responsibilities and obligations? ___
Would you describe your experience as a child in your family as happy and secure? ___
17.5 Nervous System
Paralysis ___ , weakness ___ , tremors ___ , numbness ___ , tingling ___ , loss of feeling ___ , other abnormal sensations ___ , dizziness ___ , dizziness when standing up ___
17.6 Hair
Dry hair ___ , hair loss ___ , thinning of hair (scalp, eyebrows, elsewhere?) ___ , bald spots ___ , excessive/unwanted hair ___ , premature graying of hair ___
Decrease of hair under arms ___ , in pubic area ___
Decrease of fatty tissue in pubic area (flat “mount of Venus” in women) ___
17.7 Skin and nails
Dry skin (scalp, face, arms, trunk, legs, feet?) ___ , scaly skin ___ , cracked skin ___ , acne ___ , pimples ___ , skin infection ___ , eczema ___ , rash ___ , rosacea ___ , sores/ulcers ___ , skin tags ___ , thinning skin ___ , weak, brittle, peeling or splitting nails ___ , paler complexion ___ , thin vertical wrinkles on upper lip ___ , sagging skin (e.g., cheeks) ___ , difficulty healing ___ , stomach and buttocks are skinny ___ , wrinkling of skin ___ , itching ___ , reddened skin of palms ___ , tattoos ___ , piercings ___
17.8 Bones and Joints
Joint stiffness ___ , morning joint stiffness ___ , joint pain ___ , bone pain ___ , TMJ (temporomandibular joint disorder) ___ , neck pain ___ , shoulder pain ___ , carpal tunnel syndrome ___ , back pain ___ , hip pain ___ , other ___ , osteoporosis ___ , osteopenia ___ , bone density measurement done? ___