Name: Date of Birth: Today’s Date:___

Reason you are here:

Personal Medical History: Have you ever had any of the following conditions? (Check if yes)

 Anemia  Crohn’s Disease  HIV/ AIDS

 Arthritis  Depression  Hypertension
 Asthma  Diabetes  Kidney Disease
 Cancer  Emphysema  Myocardial Infarction
 Chronic Obstructive Pulmonary  Endocrine Problems  Peptic Ulcer Disease
 Disease  GERD  Seizures
 Clotting Disorder  Glaucoma  Stroke
 Congestive Heart Failure  Hepatitis  Ulcerative Colitis

Personal Surgical History: Have you ever had any of the following surgeries? (Check if yes)

 Adrenal Gland Surgery  Colon Surgery  Kidney Surgery

 Appendectomy  Coronary Artery Bypass Graft  Neck Surgery
 Bariatric Surgery  Esophagus Surgery  Prostate Surgery
 Bladder Surgery  Gastric Bypass Surgery  Small Intestine Surgery
 Breast Surgery  Hemorrhoid Surgery  Spine Surgery
 Cesarean Section  Hernia Repair  Stomach Surgery
 Cholecystectomy  Hysterectomy  Thyroid Surgery

List names and dates of surgeries:

Medications:

Allergies:

Family History: Has anyone in your family had any of the following conditions? (Check if yes, and indicate relationship to you)

 Cancer/Polyps  Anemia  High Blood Pressure

Colon, Rectum, Anal, Stomach, Breast,  Diabetes  Anesthesia Reaction
Prostate, Uterus, Ovaries, Thyroid, Lung,  Blood Clots  Bleeding Problems
Blood, Lymphoma  Heart Disease  Hepatitis
Other  Stroke  Other
Name: Date of Birth: Today’s Date:
Social History:
Alcohol use -  Never  Occasionally  Daily Type
Tobacco use -  Never  Previously, but quit  Packs Per Day for years
Drugs use -  Never  Occasionally  Daily Type

What is your occupation?

Marital Status:  Single,  Married,  Divorced,  Widowed,  Separated

Name of spouse or significant other

Children: Number of Children Number of grandchildren

Women: Number of pregnancies , Number of deliveries - Vaginal , C-sections ,

Miscarriages , VIPs (abortions)

Cancer health habits: (Circle response)

Women Men
Breast: Monthly self-exam Y N Prostate: Yearly rectal exam Y N
Yearly physician exam Y N Yearly PSA blood test Y N
Last mammogram Y N
GYN: Yearly GYN exam Y N
Yearly PAP exam Y N
All
Colon: Yearly rectal exam Y N
Skin: High sun exposure Y N
Yearly stool test for blood Y N
Yearly skin exam Y N
Date of last colonoscopy

Review of Systems: Do you currently have any of the following symptoms or conditions (Check if yes)
General:  Nothing in this group Cardiovascular:  Nothing in this group
 Weight loss – How much lbs  Chest pain
 Loss of Appetite  Palpitations
 Fever  Heart valve problems
 Chills  Calf pain with walking
 Night Sweats  Leg swelling
 Fainting Spells
Respiratory:  Nothing in this group
Eyes:  Nothing in this group
 Chronic cough
 Eye disease or injury
 Coughing up blood
 Wear glasses or contacts
 Short of breath with activity
 Blurred or double vision
 Short of breath lying flat
Ear, Nose, Mouth, Throat:  Nothing in this group  Wheezing
 Hearing loss  Asthma
 Ear ache / infection  Bronchitis
 Ringing in ears  Pneumonia
 Nose Bleeds
Musculoskeletal:  Nothing in this group
 Bleeding gums
 Joint pain
 Mouth sores
 rthritis
 Sore throat
 Back pain
 Recent voice change
 Muscle weakness
 Runny nose / cold
 Leg pain with walking
 Sinus problems
 Leg pain at rest
 Neck stiffness / pain
 Broken bones
 Enlarged neck glands / masses
Digestive:  Nothing in this group Neurological:  Nothing in this group
 Loss of appetite  Frequent headaches
 Difficulty swallowing  Migraines
 Early satiety (fill up easy)  Weakness
 Heartburn  Seizures
 Nausea  Stroke
 Vomiting  Paralysis
 Diarrhea  Decreased sensation
 Constipation  Difficulty with speech
 Blood in stool  Dizziness
 Dark, tarry stools
 Abdominal pain Psychiatric:  Nothing in this group
 Painful bowel movements  Anxiety
 Poor control of BMs, urgency  Depression
 Mood swings
Urinary:  Nothing in this group  Phobias, fears
 Burning with urination  Panic attacks
 Weak urine stream  Suicide thoughts or attempts
 Blood in urine
 Gas or stool in urine Endocrine:  Nothing in this group
 Poor control, leakage of urine  Heat or cold intolerance
 Kidney stones  Excessive thirst
 Prostate problems  Excessive urination
 Testicular mass  Excessive Sweating
 Get up at night to urinate - Number of times per night

Gynecologic (female):  Nothing in this group Hematologic, Lymphatic:  Nothing in this group
 Irregular periods - Last period:  Prior blood transfusion
 Abnormal vaginal discharge  Easy bleeding or bruising
 Low red blood cell count (anemia)
Breast:  Nothing in this group  Low white blood cell count
 Breast lump  Prolonged bleeding with cuts, surgery
 Breast pain  Swollen glands
 Nipple discharge  Blood clots
 Use of blood thinners
Skin:  Nothing in this group  Swollen lymph nodes
 Rash
 Skin infections Allergic, Immunologic:  Nothing in this group
 Ulcers or sores  HIV infection
 Yellowing of the skin  Hepatitis
 Eczema, psoriasis, other  Imune deficiency
 Pyoderma gangrenosum, erythema nodosum  Antibiotics needed for dental work