Past Medical History Sample Clauses

Past Medical History. Yes No Yes No Vision Loss Seizures with high fever as a child or baby Glaucoma Head Trauma w/ Loss of Consciousness Loss of Hearing Back pain Recurrent Vertigo Hematological Disorder (Sickle Cell, Hemophilia) Hypertension (High Blood Pressure) Bleeding Tendency Dyslipidemia (High Cholesterol) Diabetes History of MI (“Heart Attack”) Thyroid Disease COPD/Emphysema Immunological Disorder (Rheumatoid Arthritis, Lupus, etc.) Gastrointestinal Disease Chronic Allergies/Hay Fever Liver Disease Depression Chronic Skin Condition Psychiatric illness other than depression Osteoarthritis/ Degenerative Joint Disease Kidney Disease, Prostate, or other urological disorder Chronic Sleep Disorder Tuberculosis Stroke (CVA) HIV or AIDS Alzheimer’s or Other Cognitive Disorder Encephalitis or Meningitis Xxxxxxxxx’x or Other Movement Disorder Polio Essential Tremor Infections (Lyme, Tuberculosis…) Fainting or Blackouts Gynecological problems Seizures/Epilepsy Any history of cancer Please list any other medical illnesses not already described, or clarify any noted above: Other Current Medications (please list all medications, dose, and frequency/schedule for each): Allergies (medication and food related): No Known Drug Allergies Personal/ Social History Location born and raised? Education/ Degree? Occupation? For how long? If unemployed or retired, how long? Marital Status? Living situation? (alone, etc.) Children? How many? Any history of being the victim of abuse? Any history of legal issues? (DUI, recent arrests, court proceedings, firearms offenses, etc.) Any family history of neurological or psychiatric illness? Review of Systems: (Please indicate any relevant symptoms below, or check “N/A” if no symptoms apply): Other: N/A CONSTITUTIONAL: fever fatigue night sweats weight loss  EYES: glasses blindness double vision visual field deficit drooping eyelid  EAR NOSE THROAT: hearing loss tinnitus infection trouble swallowing snoring  CARDIOVASCULAR: shortness of breath chest pain edema palpitations heart murmur  PULMONARY: cough wheezing shortness of breath coughing up blood  GASTROINTESTINAL: constipation vomiting diarrhea rectal bleeding nausea abdominal pain  SKIN: rash itchiness ulcers lesions  MUSCULOSKELETAL: back pain joint pain or stiffness joint swelling muscle cramps or weakness  NEUROLOGICAL: memory loss headache tremor dizziness paralysis or weakness (ie hemiplegia after a stroke)  HEMATOLOGICAL/LYMPHATIC: bleeding ...

Past Medical History. Please check any conditions treated currently or in the past. Anemia EENT Liver Disease Arthritis Headaches Menopause Asthma Heart Disease Psychiatric Disorders Bleeding Disorders/Clots Hepatitis Seizures Cancer High Blood Pressure Stroke COPD Hyperlipidemia Thyroid Disorders Diabetes Inflammatory Bowels Tuberculosis Depression Kidney Disease Ulcers Others REVIEW OF SYSTEMS Please check any new symptoms that you have experienced in the last 10 days. General Respiratory Gastrointestinal Genitourinary Neurological Fever Shortness of breath Change in bowels Blood in urine Dizziness Chills Cough Diarrhea Painful urination Numbness Excessive fatigue Wheezing Blood in stool Urgency Trouble walking Generalized fatigue Cardiovascular Black tarry stool Frequency Headaches Weight loss Chest pain Bloating Incomplete voiding Hema/lymph Weight gain Palpitations Constipation Stress incontinence Bruises Mouth/Nose/Throat Leg swelling Gas Urge incontinence Bleeding Ulcers Endocrine Nausea Urinating at night Enlarged glands Sinus drainage Heat intolerance Vomiting Female Reproductive Sore throat Cold intolerance Abdominal pain Abnormal vaginal bleeding Ringing ears Hair loss Difficulty swallowing Pelvic pain Skin Hot flashes Digestive changes Pelvic pressure Acne Night sweats Breast Pain with intercourse Rash Musculoskeletal Lump Pain with menstrual cycle Moles Muscle aches Nipple discharge Bleeding after intercourse Hives Muscle strains Pain Other: Muscle weakness Soreness SURGERIES OR HOSPITALIZATIONS Surgeries and/or Hospitalizations Reason Date Have you had a Colonoscopy/sigmoidoscopy? Yes or No FAMILY HISTORY Please check any family member with the following problems, and if currently alive or deceased (MGM - maternal grandmother, MGF – maternal grandfather, PGM – paternal grandmother, PGF – paternal grandfather ) Family member Mother Father Sister Brother MGM MGF PGM PGF ALIVE DECEASED Cancer (type) Diabetes (type I or II) Heart Disease High Blood Pressure Kidney disease Liver disease Osteoporosis Rheumatoid or osteoarthritis Stroke Thyroid disease Other (please list) SOCIAL HISTORY YES NO How often, how much, and type? When did you quit? Do you use tobacco products? (includes patches, e-cigarettes, gum, chew, etc.) Do you drink alcohol? Do you use or have you used street drugs? Do you use caffeine? Do you exercise? GYNECOLOGICAL HISTROY YES NO Details Are you still having periods? When was the first day of your last menstrual period? Date: Age at first period? Are y...

Past Medical History. Do you have any ongoing medical illnesses? ❑Yes ❑No If yes, what illness? ❑Asthma ❑ADHD ❑Diabetes ❑High Blood Pressure ❑Other: Are you taking ANY medication? ❑Yes ❑No If yes, what medication?___________________________________________________________________ Heart Health Questions YES NO