NAME:_________________________________________________

DATE OF BIRTH:____________________

PLEASE BRING ALL MEDICATION BOTTLES WITH YOU (BOTH PRESCRIBED AND OVER THE COUNTER).

DO YOU HAVE ANY ALLERGIES? _____ If so, please list.

REASON FOR REFERRAL TO THIS OFFICE:______________________________

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FAMILY HISTORY: Has your MOTHER, FATHER, BROTHERS OR SISTERS had any of the following problems?

Cancer Diabetes Heart Trouble

High Blood Pressure Stroke Gout

Angina Arthritis High Cholesterol

Asthma Blood Disorders

If yes, please describe:_____________________________________________________

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SURGICAL HISTORY: Have you had any surgery? Please list.

1. _____________________________Date____________Where___________________

2. _____________________________Date____________Where___________________

3._____________________________ Date____________Where___________________

4._____________________________ Date____________Where___________________

5._____________________________ Date____________Where___________________

What is your height?_____________________ Weight:___________________

What is your usual weight?_________Has your weight changed over the past year?____

Weight Gain:______________ Weight Loss:_______________

MEDICAL HISTORY: Have you ever had the following? Check

…Tuberculosis … Asthma … Allergies

… Polio … Peptic Ulcer … High Cholesterol

… Pneumonia or Pleurisy … Blood Disorder … Diabetes

… Scarlet Fever … Gout … High Blood Pressure

… Rheumatic Fever … Heart Disease … Arthritis

… Hepatitis … Cancer … Thyroid Disease

… Gallbladder Disease … Hiatal Hernia … Anemia

… Blood Transfusion … Serious Injuries … Kidney Stone

… MVP/Heart Murmur … Phlebitis/Blood Clot

If you checked any items above, please briefly explain below:__________________

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HAVE YOU HAD ANY TESTS PERFORMED WITHIN THE LAST 3 YEARS?

If yes, please check. X-rays of:

… Heart Catheterization … Chest

… Echocardiogram … Stomach

… EKG … Colon

… Treadmill Test … Gallbladder

… Nuclear Medicine Study … Back

… Others _____________________________ … Extremities

HAVE YOU HAD ANY OF THE FOLLOWING PROBLEMS RECENTLY? Check

… Weight gain or loss … Blood in stool … Cough

… Frequent urination … Fever or chills … Wheezing

… Blood in sputum … Excessive thirst … Night sweats

… Shortness of breath … Difficulty urinating … Fatigue

… Swollen painful joints … Difficulty swallowing … Paralysis

… Numbness in extremities … Calf Tenderness … Muscle cramps

… Anemia/bleeding tendency … Trouble with balance … Blurred vision

… Diarrhea/constipation … Tremors/seizures … Double vision

… Psychiatric history … Changes in appetite … Chest pain

… Ringing in ears … Nose bleeds … Palpitations

… Swollen ankles … Anxiety … Headaches

… Nausea/vomiting … Indigestion/heartburn … Dizziness

Please list any medical problems or conditions you wish to discuss with our office:

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