HPHS Patient Medical History Form

HPHS PATIENT MEDICAL HISTORY FORM – please complete this form in it’s entirety

Name: ______Date of Visit: ______Age: ______

Reason for today’s visit: ______Left Right Bilateral

Referring Physician: ______Family Physician: ______

Other Physicians /specialists you are seeing: ______
______

Medications, incl prescriptions, anti-inflammatory drugs or non-prescription medications
MED: ______DOSAGE: ______MED: ______DOSAGE: ______
MED: ______DOSAGE: ______MED: ______DOSAGE: ______
MED: ______DOSAGE: ______MED: ______DOSAGE: ______
PHARMACY NAME: ______PHARMACY PHONE NO: ______
DRUG ALLERGIES: noyes If yes, please list below LATEX ALLERGY: no yes
______

Medical History: Have you ever had any of the following conditions? IF YES, PLEASE CIRCLE & EXPLAIN
Bleeding Problems (excess bleeding dvt blood clots) noyes ______
Cancer (including skin cancer) noyes
______
Endocrine (diabetes thyroid other) noyes
______
Digestive (gastric reflux ulcers gallstones hepatitis colitis other) no yes
______
Heart Disease (chest pain arrhythmias heart attack heart failure high blood pressure
peripheral vascular disease other) noyes
______
Infectious Disease (HIV TB STD HCV chronic infections other) noyes ______
Respiratory (asthma cystic fibrosis emphysema sarcoid other) no yes
______
Neurologic (dementia depression seizures other) noyes
______
Skin (severe acne eczema psoriasis skin cancer other) noyes
______
Allergy/Rheumatology (arthritis lupus/scleroderma fibromyalgia other) noyes
______
Urinary (bladder infections prostate kidney stones kidney disease other) noyes
______
Other Medical Problems noyes ______

Surgical History: Please list any operations, including plastic surgery, you have undergone along with the dates: ______
Hospital Admissions: Please list any hospital admissions and reason for admissions: ______

TURN PAGE OVER & FILL OUT BACK2016

Review of Systems: Are you currently experiencing any of the following? If yes, circle
Constitutional: none weakness fever weight loss weight gain
Eyes:none itching excess tearing change in vision or double vision
Ears:none pain ringing buzzing imbalance loss of hearing
Nose:none obstruction bleeding chronic drainage
Neck:none stiffness swelling lumps
Mouth/Throat:none chronic sores pain difficulty swallowing
Heart/Lungs:none chest pain palpitations shortness of breath chronic cough
Digestive:none heartburn nausea/vomiting constipation diarrhea
Urinarynone incontinence retention bleeding
Muscular:none swelling weakness difficulty moving leg cramps
Skeletal:none back pain joint pain stiffness
Neurologic:none headaches migraines tremors numbness and tingling
Psychiatric:none anxiety depression hallucinations chemical dependency
Skin:none lesions rashes lumps itching
Social History:

Occupation: ______
Recreational Activities: ______
Smoking:  current every day smoker  current some day smoker  former smoker  never smoked
Alcohol: noyes frequentoccasional social

Recreational Drugs: no yes ______

Family History: Please list any major medical problems with parents, grandparents, and/or siblings:
______
______
Height: ______Weight: ______Date of Birth: ______

If pertinent, any recent X-rays, CT Scans or MRIs? noyes Date studies performed: ______Location ______
If pertinent, any recent nerve conduction studies (EMG/NCV)? noyes Date studies performed: ______Location ______
Females: Date of last mammogram ______Location ______
Anesthesia: Have you or anyone in your family had a problem with anesthesia: no yes
If yes please explain______

Patient’s Signature: ______Date: ______