HEALTH HISTORY

 (Confidential)
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Patient Name                            Today's Date
Age    Birthday Date of last physical examination 
What is your reason for visit?  
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SYMPTOMS     Check symptoms your currently have or have had in the past year.
GENERAL GASTROINTESTINAL EYE, EAR, NOSE THROAT MEN only
Chills Appetite poor Bleeding gums Breast lump
Depression Bloating Blurred vision Erection difficulties
Dizziness Bowel changes Crossed eyes Lump in testicles
Fainting Constipation Difficulty swallowing Penis discharge
Fever Diarrhea Double vision Sore on penis
Forgetfulness Excessive hunger Earache Other
Headache Excessive thirst Ear discharge  
Loss of Sleep Gas Hay fever WOMEN only
Loss of weight Hemorrhoids Hoarseness Abnormal Pap Smear
Nervousness Indigestion Loss of hearing Bleeding between periods
Sweats Nausea Nosebleeds Breast lump
.  Rectal bleeding Persistent cough Extreme menstrual pain
MUSCLE/JOINT/BONE Stomach Pain Ringing in ears Hot flashes
Pain, weakness, numbness in: Vomiting Sinus problems Nipple discharge
Arms Hips Vomiting blood Vision - Flashes Painful intercourse
Back  Legs   Vision - Halos Vaginal discharge
Feet     Neck CARDIOVASCULAR   Other
Hands Shoulders Chest pain SKIN Date of last
. High blood pressure Bruise easily menstrual period:
GENITO-URINARY Irregular heart beat Hives Date of last
Blood in urine Low blood pressure Itching Pap Smear:
Frequent urination Poor circulation Change in moles Have you had a
Lack of bladder control Rapid heart beat Rash mammogram? y n
Painful urination Swelling of ankles Scars Are you pregnant? y n
. Varicose veins Sore that won't heal Number of children
CONDITIONS     Check symptoms your currently have or have had in the past year. 
Aids Chemical Dependency High Cholesterol Prostate Problem
Alcoholism Chicken Pox HIV positive Psychiatric Care
Anemia Diabetes Kidney Disease Rheumatic Fever
Anorexia Emphysema Liver Disease Stroke
Appendicitis Epilepsy Measles Suicide Attempt
Arthritis Glaucoma Migraine Headaches Thyroid Problems
Asthma Goiter Miscarriage Tonsillitis
Bleeding Disorder Gonorrhea Mononucleosis Tuberculosis
Breast Lump Gout Multiple Sclerosis Typhoid Fever
Bronchitis Heat Disease Mumps Ulcers
Bulimia Hepatitis Pacemaker Vaginal Infections
Cancer Hernia pneumonia Venereal Disease
Cataracts Herpes Polio  
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MEDICATIONS    List medications you are currently taking:                ALLERGIES    List:
 
Pharmacy Name:

Phone: