ࡱ> HJG 0,bjbj:: PPP0$aaaaa4,\hjjjjjj{jaj@aa@@@aah@h@@aa@p=d*@\ 0@@@@a@ ':   Patient Medical History Confidential Patient Name________________________________________________ Todays Date______________ Date of Birth________________________Age__________SSN_________________________________ Address______________________________________________________________________________ Home Phone__________________________ Cell Phone ___________________________________ Height_____________ Weight____________ Emergency Contact _____________________________ E-mail Address________________________________________________________________________ Referring Doctor_______________________ Family Physician _______________________________ Chief Complaint ______________________________________________________________________ (Reason for todays visit) Current Medications Dose Frequency ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ Pharmacy ______________________________________________________________________________ Have you taken any aspirin, ibuprofen or arthritis medicine in the last two weeks?_____________________ If so when?________________________________ Do you bruise easily? ___________________________ DRUG ALLERGIES:_____________________________________________________________________ Medical Illnesses: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ Hospitalizations Date ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Surgical Procedures Date ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you ever had problems with anesthesia? __Yes __No If yes, describe:__________________________________________________________________________ Release of Records Who may have access to your medical records? Name Relation Contact Information ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Family History Family Member Medical Illnesses Mother _____________________________________________________________ Grandparents (maternal) _____________________________________________________________ Father _____________________________________________________________ Grandparents (paternal) _____________________________________________________________ Sister(s) / Brother (s) _____________________________________________________________ Social History Are you presently working or going to school full or part time? ____________________________________ Employer / School _______________________________________________________________________ Marital Status ______________ Do you live alone? _________ Who lives with you? ___________________ Do you have children? ______ If yes, how any?________________________________________________ Do you smoke? __Yes __No Cigars? ___________ Pipe?__________ Chewing tobacco?________ Cigarettes per day?_______________ How long have you been chewing or smoking ___________________ Do you drink alcohol? __Yes __ No Is it __Social __Heavy __Prior addiction? Do you take or have you taken recreational drugs? __Yes __No __Prior addiction Do you have any difficulty sleeping? __Never __Often __Sometimes __Getting to sleep __Staying awake Does anyone complain that you snore? __Yes __ No Do you stop breathing at night? __Yes __No Do you wake up tired in the morning? __Yes __ No Do you fall asleep in the daytime? __Yes __No Caffeine intake: _________________________________________________________________ per day Do you exercise? __ Yes __No Type/Frequency:___________________________________ Are you at risk for AIDS? If yes, explain ____________________________________________________ Review of Systems Are you currently having, or have you had problems with: (check all that apply) General well-being __ Fever __ Weight loss (>10#) __ Excess fatigue __ Recurrent Nausea / vomit __ Night sweats Eyes __ Wear glasses Date of last exam ______ __ Infections __ Injuries __ Glaucoma __ Cataracts __ Blurred vision __ Trouble focusing __ Recent change in vision Ears, Nose, Mouth and Throat __ Wear hearing aids Date of last exam_______ __ Hearing loss __ Ear infection __ Pressure in ears __ Ringing in ears __ Pain in ears __ Balance disturbance __ Itching in ears __ Dizziness __ Nasal congestion __ Nasal drainage __ Nosebleeds __ Sinus problems __ Sinus infections __ Sinus headaches __ Throat infections __ Difficulty swallowing __ Lip or mouth sores __ Sore throats Respiratory __ Chronic cough __ Emphysema __ Bronchitis __ Asthma __ Chronic obstruction __ Pulmonary disease __ Shortness of breath __ Oxygen use at home __ Pneumonia __ Lung cancer __ Tuberculosis __ Blood in saliva Date of last chest X-ray_____ Cardiovascular __ Chest pain Date of last EKG _______ __ Heart attack __ High blood pressure __ Low blood pressure __ Irregular heartbeat __ Heart murmur __ Arm and leg swelling __ High cholesterol Gastrointestinal __ Blood in vomit __ Indigestion __ Nausea / vomiting __ Jaundice __ Abdominal pain __ Change in bowel habits __ Ulcers or Gastritis __ Colon, liver, stomach cancer __ Hepatitis Hematologic __ Anemia __ Hemophilia __ Easy bleeding / bruising __ Swollen glands Genitourinary __ Urinary tract infection __ Painful urination __ Blood in urine __ Difficulty urinating __ Incontinence __ Kidney stones __ Prostate cancer __ Endometriosis __ Uterine, ovarian or cervical cancer Neurological __ Disorientation __ Fainting / blacking out __ Light headedness __ Seizures __ Stroke __ Mini-stroke __ Memory problems __ Concentration problems __ Speech problems __ Facial weakness/ spasms __ Muscle weakness __ Coordination problems __ Uncontrolled shaking __ Headache __ Migraine Endocrine __ Diabetes __ Hormone problems __ Low blood sugar __ Thyroid disease __ Increased appetite __ Excessive thirst __ Excessive urination __ Temperature intolerance __ Pituitary gland problems __ Bleeding tendencies Immunologic __ Environmental allergies __ Hay fever __ Food allergies __ Immune system problems __ Connective tissue disease __ Frequent colds / infections Skin __ Eczema or psoriasis __ Dermatitis __ Dry or scaling skin __ Rashes __ Changes in skin color __ Changes in moles __ Skin cancer __ Breast pain or swelling Date of last Mammogram _____________ Musculoskeletal __ Broken bones list:_______________ __ Arm or leg weakness __ Joint pain or swelling __ Back pain __ Arthritis Psychiatric __ Anxiety __ Depression __ Manic/Depression __ Schizophrenia __ Considering suicide / homicide __ Panic attacks __ Sudden mood swings __ Emotional difficulties __ Insomnia _ __ Other psychiatric problems __ Under psychiatric care __ Desiring psychiatric care ________________________________________________________________________________________________________The above information is accurate to the best of my knowledge. ____________________________________________________ ________________________ Patient Signature Date I have reviewed the above information with the patient. _____________________________________________________ _________________________ Boris Karanfilov, M.D. Date $&=     $ / f  = >  \mnotu{}ɖɖ{l{aUahrthp5CJaJhp5>*CJaJh|hp56>*CJaJhp56>*CJaJhDHqhpCJaJhphrthp5>*CJaJhpCJaJhp5CJaJh|hp5CJaJhpCJaJhrthpCJaJhpCJaJhrthpCJaJhbp5>*CJ aJ hrthbp5>*CJ aJ !%&~- . 4 5   / > ? gdp$a$gdp[\ou$|}LMk Z N$a$gdpgdp}LM`fj   ߛqi^Sh|hpCJaJhp5>*CJaJhpCJaJh|hp5>*CJaJhDHqhp56CJaJh|hp56CJaJh 9hpCJaJh 9hp5>*CJaJh 9hp5CJaJhp5CJaJhp56CJaJhp5>*CJaJhpCJaJhrthpCJaJhrthp5>*CJaJ DJMW%+169m}+/0|}#$678̳̥̾hp5CJaJhpCJaJhp5CJ aJ h*Php56CJaJhDhpCJaJhDhp56CJaJhp56CJaJhA>(hpCJaJhpCJaJh|hpCJaJh hpCJaJ4Dmn01#PQNO$a$gdpgdpO\]#678,:$a$gdpgdpC!O!""""U#h#$$'$m$z${$G%U%r&s&|&}&S'V'b'''(((J)V)*+b+z+{+++ߵߧߙߙߍ߁xhp6CJaJh"hp6CJaJh/hp5CJaJh3Thp5>*CJaJhOhp5>*CJaJhEphp5>*CJaJhZhp5>*CJaJhPhp5>*CJaJhpCJaJhv hp5>*CJaJhp5>*CJaJ-:FR_q $ 7 G ^ q ~ !!/!?!@!gdp@!A!B!C!O!`!m!{!!!!!!!! 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