Escolar Documentos
Profissional Documentos
Cultura Documentos
Personal History
Weight____________________( lbs or Kg )
1.
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2.
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3.
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4.
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5.
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Current Medications
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Current Herbs / Vitamins/ Homeopathy/ Supplements
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Dose
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Dose
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Times / Day
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____________________________
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Times / Day
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Patient Name:
Allergies
Alzheimers
Anemia
Arthritis
Asthma
Birth Defects
Bleeding Disorder
Breast Cancer
Cancer
Depression
Diabetes
Emphysema
Epilepsy
Glaucoma
Heart Disease
High Blood Pressure
IBS
Kidney Disease
Liver Disease
Mental Illness
Migraine Headaches
Pneumonia
Stroke
Tuberculosis
Ulcers
Other
Mother
Father
Grandparents
Sister/ Brother
Spouse
Children
Patient Name:
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Typical
breakfast__________________________________________________________________________________________________
_
Typical lunch
_______________________________________________________________________________________________
Typical
dinner_______________________________________________________________________________________________
Typical
snacks_______________________________________________________________________________________________
Devices
Do You Use:
___Eyeglasses
______Contact Lens
______Hearing Aid
______Dentures
______ Pacemaker
______Artificial Limbs
REVIEW OF SYSTEMS
Check any symptoms that currently apply to you:
Constitutional
Mouth, Throat
___ poor appetite
___ fevers
___ chills
___ food craving
___ weight loss
___ weight gain
___ fatigue
Eyes
Immune System
____too many infections
____allergies to food
____allergies to environment
___ other concerns
Blood System
Sexual Organs
____ sores on genitals
____ lumps or swelling
____ erection problems
____ premature ejaculation
____pain with sex
____infertility
____repeated infections
____aversion to sex
Thermal State
___hot
___chilly
Patient Name:
Muscles, Bones & Joints
____neck pain
____back pain
____muscle pain
____ painful joints: R__L__
____shoulder ____elbow
____hip____ knee ___ankle
____wrist _____fingers
____joint swelling
____muscle weakness
____muscle cramps
Skin, Hair
____ psoriasis
____ warts
____ freckles
____ itching, hives
____ hair loss
____ dry skin, eczema
____indigestion
____belching/ flatulence
____difficulty swallowing
____heartburn/ ulcer
____nausea
____ liver trouble
____ vomiting
____ diarrhea
____ cramping bowels
____ food allergies
____constipation
____ abdominal pain
____rectal pain/ itching
____ hemorrhoids/ piles
____ blood in stool
____painful urination
____wake up to urinate
____kidney stones
____ loss of control
____ frequent urination
____ sudden urging
____ blood/pus urine
____urine infection UTI
Women
Reproductive
____emotional
____sleep
Additional Symptoms -___________________________________________________________________________________________________________
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IF NOT NOTED IT IS EITHER NEGATIVE, NON-CONTRIBUTORY, AND/ OR NON-PERTINENT.
Patient Name:
Mammogram _________ Pap Smear__________ Self Breast Exam ___________Breast Exam by Doctor____________
Blood test for Cholesterol _________ Blood Sugar ________Other Blood tests__________________________________
Immunizations: Tetanus_______________Hepatitis______________MMR____________________Flu Shot_____________________
Test for Blood in stool_______ Rectal Exam ______________Feeling the Prostate_________ Scope Lower Bowel_______________
Self Exam Testicle ___________Testicle Exam by Professional____________
Anatomy\Procedure
Back
Brain
Chest
Colon
Extremities (Arm/ Leg)
Gallbladder
Kidney
Neck
Pelvis
Stomach
Other
X-ray
MRI
CT Scan
Ultrasound
Bone Scan
EKG
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Date Patient/ Guardian signature that filled out the history
Address;
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EEG
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Cell
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