ROCKY MOUNTAIN INFECTIOUS DISEASE SPECIALISTS, P.C.
Today’s Date:______
Name:______Age:_____ Weight:______Height:______
Referring Physician:______Reason for Visit:______
Any diagnostic tests for present problem? ______Last EKG ______Last Chest X-ray______
ALLERGIES: Are you allergic to any medicines (including iodine, tape, latex)? Yes No If yes, please complete the following:
Allergy Type of Reaction
OPERATIONS: List ALL operations you have had:
Operation Date Operation Date
Have you had any problems with general anesthesia? Yes No Have you ever had a blood transfusion? Yes No
MEDICATIONS: List any medicines including steroids, inhalers, herbals (& over-the-counter aspirin) you are taking now:
Medication Dose Frequency Medication Dose Frequency
Do you take antibiotics prior to procedures? Yes No Are you on oxygen? Yes No
SOCIAL HISTORY:
Do you smoke? Yes No If yes, how much per day? ______Have you ever smoked? Yes No Date quit ______
Do you drink alcohol? ...... No Yes If yes, how often? ______
Are you using illicit drugs; i.e., marijuana, cocaine, etc.? … No Yes If yes, which drug(s)? ______
Are you on a special diet? ...... No Yes If yes, describe______
What is/was your occupation?______
FAMILY MEDICAL HISTORY - Please indicate if any family member has had the following:
Relationship Relationship
Cancer No Yes ______Bleeding problems No Yes ______
Blood pressure problems No Yes ______Diabetes No Yes ______
Heart problems/chest pain No Yes ______Epilepsy/seizures No Yes ______
Hepatitis/ jaundice No Yes ______Asthma/breathing problems No Yes ______
Reaction to anesthesia No Yes ______
______
Physician Signature Date *Continued on next page è
MEDICAL HISTORY - Have you been diagnosed with and/or are you currently having any of the following symptoms:
Genitourinary/GYN: Yes Constitutional: Yes
Cancer ...... Fever ......
Kidney problems/stones . . . . . Chills ......
Bladder infections ...... Weight Loss......
Kidney failure ...... Headaches ......
Prostate infections ...... Night sweats ......
Uterine problems......
Ovarian problems ...... Musculoskeletal/Skin:
Do you have any muscle/bone problems? Yes No
# of pregnancies ____ # of live births ______
Any possibility of pregnancy? ______Neck problems/joint pain . . .
Loss of sensation ......
Rash/skin breakdown ......
Arthritis (type)______
Fractures ______
Osteoporosis ......
Cardiac:
Have you had any heart problems? Yes No
Yes
Chest pain (Angina) ......
Palpitations/heart racing......
Congestive heart failure......
Heart attack......
High blood pressure ......
Pacemaker ......
Heart valve ......
Rheumatic fever ......
Digestive (Stomach/Bowel):
Have you had any digestive problems? Yes No
Yes
Abdominal pain ......
Nausea/vomiting ......
Constipation ......
Diarrhea ......
Colitis ......
Diverticulitis ......
Hiatal hernia/reflux ......
Irritable bowel syndrome . . . . .
Ulcers ......
Pancreatitis ......
Rectal bleeding/rectal pain . . .
Change in bowel habits . . . . .
Hemorrhoids ......
Endocrine: Have you had problems? Yes No
Yes Tired/sluggish ......
Excessive thirst ......
Diabetes......
Thyroid ......
Blood/Immune System:
Have you had problems? Yes No
Swollen glands ......
Anemia ......
Cancer ......
Cirrhosis ......
DVT/phlebitis/clots ......
Jaundice......
Lupus ......
Neurologic/HEENT:
Have you had any neurologic problems? Yes No
Yes
Numbness/tingling ......
Loss of strength ......
Stroke (CVA)......
Headaches-type______
Seizures/epilepsy ......
MS ......
Psychologic (Emotional): Any problems? Yes No
Yes
Nervousness ......
Anxiety ......
Depression ......
Other ______
Respiratory:
Have you had any breathing problems? Yes No
Yes
Wheezing ......
Shortness of breath......
Productive or bloody cough
Asthma ......
Emphysema/COPD ......
Bronchitis ......
Pneumonia ......
Pulmonary embolism . . . . .
Communicable Diseases:
Yes
AIDS/HIV......
Hepatitis A/B/C ......
Sexually transmitted disease
Tuberculosis ......
Mumps ......
MEDICAL HISTORY - Have you been diagnosed with and/or are you currently having any of the following symptoms:
Neurologic/HEENT:
Have you had any neurologic problems? Yes No
Yes
Numbness/tingling ......
Loss of strength ......
Stroke (CVA/TIA)......
Headaches-type______
Seizures/epilepsy ......
MS ......
Ear problems ......
Eye problems ......
Nose/sinus problems ......
Throat problems ......
Musculoskeletal/Skin:
Do you have any muscle/bone problems? Yes No
Yes
Back or neck problems/joint pain
Loss of sensation ......
Rash/skin breakdown ......
Arthritis (type)______
Fractures ______
Osteoporosis ......
Endocrine: Have you had problems? Yes No
Yes Tired/sluggish ......
Excessive thirst ......
Diabetes......
Thyroid problem......
Respiratory:
Have you had any breathing problems? Yes No
Yes
Wheezing ......
Shortness of breath......
Productive or bloody cough . . .
Asthma ......
Emphysema/COPD ......
Bronchitis ......
Pneumonia ......
Pulmonary embolism ......
Tuberculosis ......
Cardiac: Have you had any heart problems? Yes No
Yes
Chest pain (Angina) ......
Palpitations/heart racing . . . . .
Congestive heart failure......
Heart attack......
High blood pressure ......
Pacemaker ......
Heart valve ......
Rheumatic fever ......
Cancer:
Have you ever been diagnosed with cancer? Yes No
Type: ______
Treatment: ______
Digestive (Stomach/Bowel):
Have you had any digestive problems? Yes No
Yes
Abdominal pain ......
Nausea/vomiting ......
Constipation or diarrhea . . .
Hepatitis ......
Colitis ......
Diverticulitis ......
Hiatal hernia/reflux ......
Irritable bowel syndrome . .
Ulcers ......
Pancreatitis ......
Rectal bleeding/rectal pain
Change in bowel habits . . . .
Hemorrhoids ......
Genitourinary/GYN: Any problems? Yes No
Yes
Kidney problems/stones . . . .
Bladder infections ......
Kidney failure ......
Prostate infections ......
Uterine problems......
Ovarian problems ......
Blood/Immune System: Any problems? Yes No
Yes
Swollen glands ......
Anemia ......
Cirrhosis ......
DVT/phlebitis/clots ......
Jaundice......
Lupus ......
Psychologic (Emotional): Any problems? Yes No
Yes
Nervousness ......
Anxiety ......
Depression ......
Other ______
Constitutional: Any problems? Yes No
Yes
Fever ......
Chills ......
Weight Loss......
Night sweats ......
Communicable Diseases: Any problems? Yes No
Yes
AIDS/HIV......
Hepatitis A/B/C ......
Sexually transmitted disease
Tuberculosis ......
UPDATED 1/23/06 JO