ࡱ> tvsy ^\bjbj .j{{H    8B<~ eA"JJJJJ%%%@@@@@@@$C9F@u%%@JJAFJJ@@R<?JPTozR=p@5A0eA>FHF<?F?%9G S]%%%@@%%%eAF%%%%%%%%% : Patient Name: _____________________________________ Date:_____________________________ ALLERGIES to medications, and the REACTION or side effect you get from it:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SOCIAL HISTORYMarital status: Single Married Widowed Divorced Occupation (Or prior occupation) _____________________________________________Retired?: Race/Ethnicity:________________________________________ Do you exercise regularly? Yes NoSUBSTANCES: Check (") whether current or past use of the following substances. SubstanceNeverCurrentPastAmount per dayCaffeineTobaccoAlcoholStreet DrugsPATIENT MEDICAL HISTORY Do you now, or have you ever had, the following conditions?  Heart Disease Hypertension Heart Attack or Stroke High cholesterol Measles or Mumps Meningitis Hepatitis Rheumatic Fever Scarlet Fever  Polio Cancer Headaches Blood Transfusions Surgery (please list) ____________________________________________________________________________________________________________________________________________________________________ FAMILY MEDICAL HISTORY Does anyone in your family have the following? Specify relationship and age at time of problem. High Blood Pressure Yes No Ear/Nose/Throat Yes No Heart problems Yes No Diabetes Yes No Kidney problems Yes No Stroke Yes No Blood clots in legs or lungs Yes No Cancer Yes No Type:_________ Bleeding/clotting disorders Yes No Other______________________________________ Is your mother alive? Yes No Is your father alive? Yes No MEDICATIONS you are currently using________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________  WHY ARE YOU HERE TODAY?__________________________________________________________________________________________________________________________________________________________________________OTHER CURRENT MEDICAL PROBLEMS?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SYMPTOMS Circle any persistent symptoms you currently have or have had in the PAST YEAR. ENT W   & ( 4 6 H L Z \ ^ ` r t  $ & ( * ɹxxh1CJaJh=[5CJ\aJhq#CJaJh=[CJaJh5NCJOJQJ^JaJh5NCJaJhRD CJaJhRD CJaJhRD CJaJhRD 5CJ\aJhu56CJ\]aJhuCJaJhu5CJ\aJht5CJ\aJ/ckd$$Ifl#$'0'4 la?yt) $IfgdRD  ckdA$$Ifl#$'0'4 la?yt) $IfgdRD skd$$Ifl#$'  0'4 la?p yt)   v * }}}} $IfgdRD skd$$Ifl#$'  0'4 la?p yt)$If .($Ifckd!$$Ifl#$'0'4 la?yt) $IfgdRD ckd$$Ifl#$'0'4 la?yt) Ikd$$Iflr #!MK0'4 la?yt)$If      Ikd{$$Iflr #!MK0'4 la?yt)$If   0 2 T V  $&(,.DHLxz~"&@DHRTXfhļ~v~~~vh[lfCJaJhFhFCJaJ h=[h[lfCJOJQJ^JaJh=[h[lfCJaJh'CJaJh[lfCJOJQJ^JaJh[lfCJaJh[lfh[lfCJaJh[lf5CJ\aJhRD CJaJhRD 5CJ\aJh1CJaJh=[5CJ\aJ.  ( * , . 0 OIIIII$IfkdD$$Iflr #!MK0'4 la?yt)0 2 L N P R T OIIIII$Ifkd $$Iflr #!MK0'4 la?yt)T V OI$Ifkd$$Iflr #!MK0'4 la?yt) "ckd]$$Ifl#$'0'4 la?yt)$Ifskd$$Ifl#$'  0'4 la?p yt)(Hz"DTh $Ifgd[lf $Ifgd=[hl~% .8:<BDLNXZbfjlļ̼̼̼~~~~vhvhh5NCJOJQJ^JaJh5NCJaJhFCJaJh>h>>*CJaJh>h}>*CJaJh}CJOJQJ^JaJh}CJaJh>CJaJh]CJaJh]CJaJh]5CJ\aJh[lfCJaJh=[h[lfCJaJhFCJaJh[lfCJOJQJ^JaJ'$Ifvkd$$Iflc0f#0'4 la?yt)^<"}}} $Ifgd5N$Ifskd $$Ifl$'  0'4 la?p yt)l~@DHJ\^|"&(:<tvx XZ\dhlnǻǻ夻夻h>CJaJh5NCJOJQJ^JaJh>>*CJaJh>h>>*CJaJh}CJOJQJ^JaJh}CJaJh]CJaJh5NCJaJ#h>h>>*CJOJQJ^JaJ<D1ckd $$Ifl$'0'4 la?yt)$Ifckd/ $$IflV$'0'4 la?yt) ,48<@BDTlxˊwldhq#CJaJhq#5CJ\aJh15CJ\aJhuCJaJhFCJaJhd^CJaJhuCJaJhNhuCJaJhu5CJ\aJh]CJaJhNh1CJaJh]CJaJhCJOJQJ^JaJhNCJaJhNhNCJaJhCJaJh]%$IfskdQ $$Ifl$'  0'4 la?p yt)$Ifckd $$Ifl$'0'4 la?yt)HI"ckdB $$Ifl$'0'4 la?yt)$Ifskd $$Iflh$'  0'4 la?p yt)Ihjkluv|PQ QQQQ,RJR|SSRTTTvTUUVWW WpWҹҫ~zrznzzzczz\z h'56h)h)CJaJh'h)CJaJh)Uh)h)56h1CJaJh{yh1CJaJhu56CJ\]aJh156CJ\]aJh156CJ\]aJh{y5CJ\aJh15CJ\aJh0_h0_<h]CJaJhu5CJ\aJh1CJaJ$Iijjskd $$Ifl$'  0'4 la?p yt)$Ifjklv$&`#$/Ifgdugd0_ckd$$Ifl$'0'4 la?yt)VPxPPPQkPPPPP & Fd$&`#$/Ifgd)d$&`#$/Ifgd)|kd$$Ifl'\(  6` 0($4 lap yt)Pain or discharge (running) from your ears Bothersome cough Hay fever or constantly stuffed up nose Nosebleeds Ringing in your ears EYE Pain in your eyes or see rainbows (halos) around lights Complete or partial blindness or seeing double Glaucoma (hardening of the eyeball)? CARDIOVASCULAR High blood pressure Swelling in your ankles or feet Chest pain Wake up at night out of breath Difficulty breathing after climbing one flight of stairs RESPIRATORY Trouble breathing Coughed up blood Asthma or wheezing Tuberculosis (TB) Abnormal chest x-ray? GASTROINTESTINAL Vomit blood or have black tarry stools Severe stomach pains Frequent periods of belching, heartburn, vomiting, indigestion, diarrhea GENITOURINARY Pain or burning on urination or trouble starting your stream Urinate more frequently than usual or get up at to urinate Have you ever had kidney or bladder problems MUSCULOSKELETAL Swollen or painful joints Neck, back, or leg pain ENDOCRINE Diabetes Sugar in your urine of blood Have you ever had goiter in your neck Thyroid disease WOMEN ONLY Have you experienced menopause? HEMILYPH Bruise or bleed easily Become tired or exhausted easily Anemic Problems with your blood Sickle cell anemia Have you ever had syphilis or any venereal disease? NEUROPSYCHIATRIC Feeling dizzy Difficulty with your balance Had fits, seizures, or convulsions Periods of unconsciousness Loss of strength or feeling constant numbness in any part of your body Nervous breakdown Wanted to see a doctor because of nervousness, Depression, or emotional problems?      Q QQQQ*R,RJRrRRRSzS|SSSST&TRT & Fd$Ifgd) & Fd$Ifgd) & Fd$Ifgd)d$Ifgd)$&`#$/Ifgd ,RTTTvTTTUUUVVVV W>WnWpWWW & F d$Ifgd) & F d$Ifgd) & Fd$Ifgd) & Fd$Ifgd)d$Ifgd)$&`#$/Ifgd ,pWW@XVXXXXYZZ[<\>\@\B\D\H\J\N\P\T\V\\\^\ļh2jh2Uh ,h]CJaJh ,h)CJaJh'h)h)5h ,h)6CJaJh)h)h)56WW>X@XVXXXXXXY,Y^YYYYZ.ZhZZ & F d$Ifgd) & F d$Ifgd)$&`#$/Ifgdud$Ifgd) & F d$Ifgd)ZZr[[<\>\@\B\HFkd$$IflF ( x 6`0($    4 layt)$&`#$/Ifgd , & F d$Ifgd)B\F\H\L\N\R\T\X\Z\\\^\gdRD ,1h/ =!"#$% $$If?!vh#v$':V l0'5$'/ 4a?yt)$$If?!vh#v$':V l  0'5$'/ 4a?p yt)$$If?!vh#v$':V l0'5$'/ 4a?yt)$$If?!vh#v$':V l  0'5$'/ 4a?p yt)$$If?!vh#v$':V l0'5$'/ / 4a?yt)$$If?!vh#v$':V l0'5$'/ 4a?yt)$$If?!vh#v#v!#vM#v#vK:V l0'55!5M55K/ 4a?yt)$$If?!vh#v#v!#vM#v#vK:V l0'55!5M55K/ 4a?yt)$$If?!vh#v#v!#vM#v#vK:V l0'55!5M55K/ 4a?yt)$$If?!vh#v#v!#vM#v#vK:V l0'55!5M55K/ 4a?yt)$$If?!vh#v#v!#vM#v#vK:V l0'55!5M55K/  / 4a?yt)$$If?!vh#v$':V l  0'5$'/ 4a?p yt)$$If?!vh#v$':V l0'5$'/ 4a?yt)$$If?!vh#v#v:V lc0'554a?yt)$$If?!vh#v':V l  0'5'/ 4a?p yt)$$If?!vh#v':V lV0'5'/ 4a?yt)$$If?!vh#v':V l0'5'/ 4a?yt)$$If?!vh#v':V l  0'5'/ 4a?p yt)$$If?!vh#v':V l0'5'/ 4a?yt)$$If?!vh#v':V lh  0'5'/ 4a?p yt)$$If?!vh#v':V l0'5'/ 4a?yt)$$If?!vh#v':V l  0'5'/ 4a?p yt)$$If?!vh#v':V l0'5'/ 4a?yt)$$If!vh#v\(:V l  6` 0($5\(/ 4p yt)$$If$!vh#v #vx#v :V l 6`0($5 5x5 4yt)^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH R`R )Normal d CJOJQJ_HaJmH sH tH DA D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List VoV ]Default 7$8$H$!B*CJ_HaJmH phsH tH H@H  Balloon TextCJOJQJ^JaJ44 uHeader  !4 "4 uFooter  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] Vj  hlpW^\ $1  0 T IjQRTWZB\^\!"#%&'/02348@0(  B S  ?*ϼWWC/mitelunifiedcommunicatorsmarttag/smarttagmodule MySmartTag Er HJKMNPQSW HJKMNPQSW3;;"&<?O#%%JPQTUYZ_``ir #$$GPx Er!"GHHKKW;;"&<?O#%%JPQTUYZ_``ir #$$GPx GHHJKKMNPQSW =N|Qbq` K30T4z6 t[MRW֪bS괾`}20_)q=[YHJ@    @{p3333 ' V@  @0@PUnknown G*Ax Times New Roman5Symbol3. *Cx Arial?Wingdings 27.@ Calibri5. .[`)Tahoma?= *Cx Courier New;WingdingsA$BCambria Math"hJsG\G h #h #!24?? 3QHP ?]2!xx History & Physical Form forcheriet Kristin Egan<         Oh+'0  8 D P \hpxHistory & Physical Form forcherietNormalKristin Egan5Microsoft Office Word@hx@(h!9d@6 +[v@Fozh՜.+,0 hp|  # ? History & Physical Form for Title  !"#$%&'()*+,-./012345789:;<=>@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abdefghijlmnopqruRoot Entry FpţTozwData 61Table?FWordDocument.jSummaryInformation(cDocumentSummaryInformation8kCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q