ࡱ> %` bjbj"x"x 0@@|||||||4>4>4>8l>t>TRb@B@B@B@B@BCCCQQQQQQQ$2ThV R|CCCCC R||@B@BRSDSDSDCp|@B|@BQSDCQSDSD||SD@B4B cޒ4>CpSDwDl R0RSD(WC(WSD(W|SD$SDCCC R RCXCCCRCCCC94>4>||||||  Confidential Health History Name: Date: Birthdate: Age: Date of last physical examination: Occupation: Reason for visit today: Medications List all medications you are currently taking Allergies List all allergies Symptoms Check {P} symptoms you currently 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 WOMEN only Loss of sleep Gas Hay fever Abnormal Pap Smear Loss of weight Hemorrhoids Hoarseness Bleeding between periods Nervousness Indigestion Loss of hearing Breast lump Numbness Nausea Nosebleeds Extreme menstrual pain Sweats Rectal bleeding Persistent cough Hot flashes Muscle/Joint/Bone Pain, weakness, numbness in: Stomach pain Ringing in ears Nipple discharge Vomiting Sinus problems Painful intercourse Arms Hips Vomiting blood Vision  Flashes Vaginal discharge Other Date of last menstrual period Date of last Pap Smear Have you had a mammogram? Are you pregnant? Number of children Back Legs Cardiovascular Vision  Halos Feet Neck Chest pain Skin Hands Shoulders High blood pressure Bruise easily Genito-Urinary Irregular heart beat Hives Blood in urine Low blood pressure Itching Frequent urination Poor circulation Change in moles Lack of bladder control Rapid heart beat Rash Painful urination Swelling of ankles Scars Varicose veins Sores that won t heal Medical History Check {P} the medical conditions you have or have had in the past. AIDS Chemical dependency Herpes Polio Alcoholism Chicken Pox High Cholesterol Prostate Problem Anemia Diabetes HIV Positive Psychiatric Care Anorexia Emphysema Kidney Disease Rheumatic Fever Appendicitis Epilepsy Liver Disease Scarlet Fever Arthritis #$+,127CFGLNOqrt Ͼvfv]fvh9QhXCJhO hX5;CJOJQJh9QhXCJOJQJh@hXCJOJQJh9QhX>*CJOJQJh9QhX>*CJh9QhXCJh9QhXCJOJQJ!h9QhXB*CJOJQJphhO hX5;B*CJ ph'hO hX5;B*CJ OJQJphh9QhX5OJQJ8uiYYYC($IfgdXlK$$Iflzkd$IfK$L$TlQ'L'  t 0L'644 lap T$$Ifa$gdXlK$gdX $IflK$jkd$IfK$L$TlQ'L' t0L'644 laT nn$IflK$kdE$IfK$L$Tl409Q'4 t0L'644 laT    nn$IflK$kd$IfK$L$Tl409Q'4 t0L'644 laT    nn$IflK$kd$IfK$L$Tl409Q'4 t0L'644 laT    nn$IflK$kd$IfK$L$Tl409Q'4 t0L'644 laT     h j l z |   2 4 N P R j l  * , R T V j l ֶֶֶ֛֨h9QhX5CJaJh9QhXCJOJQJaJhO hXCJOJQJhQhX5CJOJQJh9QhX5CJOJQJ"hO hX5;CJEHOJQJhO hX5;CJOJQJh9QhXCJOJQJhhXCJOJQJ2  j n$IflK$kd$IfK$L$Tl409Q'4 t0L'644 laTj l | {{{{$$Ifa$gdXlK$lkdU$IfK$L$TlQ'L' t0L'644 laT  2 N YEEEE$IfgdXlK$kd$IfK$L$Tl-\ hGQ' p   t0L'644 laTN P j YEEEE$IfgdXlK$kd$IfK$L$Tl\ hGQ'& &p && t0L'644 laT * R YEEEE$IfgdXlK$kd$IfK$L$Tl\ hGQ'& &p && t0L'644 laTR T j YEEEE$IfgdXlK$kdK$IfK$L$Tl\ hGQ'& &p && t0L'644 laT   $ & D F H f h "$&(FHRTjl$&(BD^`(*LƶhQhX5CJOJQJaJ"hO hX5;CJOJQJaJh9QhX5CJaJhO hXCJOJQJh9QhXCJOJQJaJH  $ D YEEEE$IfgdXlK$kd $IfK$L$Tl\ hGQ'& &p && t0L'644 laTD F f YEEEE$IfgdXlK$kd $IfK$L$Tl\ hGQ'& &p && t0L'644 laT $YEEE.$$Ifa$gdXlK$$IfgdXlK$kd $IfK$L$Tl\ hGQ'& &p && t0L'644 laT$&FRjYEEEE$IfgdXlK$kds $IfK$L$Tl\ hGQ'& &p && t0L'644 laT$YEEEE$IfgdXlK$kd= $IfK$L$Tl\ hGQ'& &p &' t0L'644 laT$&B^YEEEE$IfgdXlK$kd $IfK$L$Tl\ hGQ'& &p &' t0L'644 laTYEEEE$IfgdXlK$kd $IfK$L$Tl\ hGQ'& &p &' t0L'644 laT(LrYEEEE$IfgdXlK$kd$IfK$L$Tl\ hGQ'& &p &' t0L'644 laTLNrt 02VXZ\pr"$&JLNZ\xzȻ䯠仠sh9QhX>*CJOJQJhO hX>*CJOJQJaJh9QhXCJOJQJaJhQhXCJOJQJaJh@hX5CJaJh9QhXCJOJQJhO hX5;CJOJQJh9QhX5CJaJh9QhXCJOJQJaJhO hXCJOJQJ- YI8$$IfgdXlK$$IflK$$Iflkd}$IfK$L$Tl\ hGQ'& &p &' t0L'644 laT 0VXZpDkdM$IfK$L$Tl4\ hGQ'`& &p &' t0L'644 laT$IfgdXlK$$XDDDD$IfgdXlK$kd%$IfK$L$Tl4\ hGQ' & &p &' t0L'644 laT$L\^F|~$IfgdXlK$$IfgdXl($IfgdXl >DFjxz~ "$&(2ĸ񞏫񞏫m"hO hX5;CJOJQJaJhO hX5;CJOJQJhQhXCJOJQJaJh9QhXCJOJQJhO hXCJOJQJh9QhX5CJaJh9QhXCJOJQJaJh9QhX>*CJOJQJhO hX>*CJOJQJaJh9QhXCJOJQJaJ*~!kd$IfK$L$Tl4r hGQ'&&p && t0L'62s244 lap2T$IfgdXlK$!kd8$IfK$L$Tl4r hGQ'&&p & & t0L'62s244 lap2T "$$Ifa$gdXlK$$IfgdXlK$"$4L4 $IfgdXlK$kdm$IfK$L$Tl4r hGQ'&'p & ' t0L'644 lapT2468LNxz| FHJLZ^`bdȹժȪsժȪsժȪhQhXCJOJQJaJh@hX5CJaJhO hX5;CJOJQJh9QhX5CJaJh9QhXCJOJQJaJh@hXCJOJQJaJh9QhXCJOJQJh9QhXCJOJQJaJhO hXCJOJQJhQhXCJOJQJaJ-Lx$IfgdXlK$*$IflK$kd$IfK$L$Tl4r hGQ'&'p & ' t0L'644 lap2T,kd$IfK$L$Tl4\ hGQ'& 'p '  t0L'644 lap(T$IfgdXlK$H\^`Akd$IfK$L$Tl4\ hGQ'& 'p '  t0L'644 laT$IfgdXlK$ 2@BAkd$IfK$L$Tl4\ hGQ'& 'p '  t0L'644 laT$IfgdXlK$  0246>BDFHjln 02׹׹נrȭ"hO hX5;CJEHOJQJhO hX5;CJOJQJh9QhX5CJaJhhXCJOJQJh@hX5CJaJh9QhXCJOJQJaJhQhXCJOJQJaJh9QhXCJOJQJh9QhXCJOJQJaJhO hXCJOJQJ,BDlUAAAA$IfgdXlK$kdy$IfK$L$Tl4\ hGQ'& 'p '  t0L'644 laTUAAAA$IfgdXlK$kdV$IfK$L$Tl4\ hGQ'& 'p ' ' t0L'644 laTUA$IfgdXlK$kdA$IfK$L$Tl4\ hGQ'& &p &&  t0L'644 laT~~~~$IfgdXlK$lkd:$IfK$L$TlQ'&L' t0L'644 laT  "$<>@bdf&(*HJLlnpr*,.>@BPRTVdfUh@hX5CJaJhO hXCJOJQJh9QhXCJOJQJaJh9QhXCJOJQJaJN">dYEEEE$IfgdXlK$kd$IfK$L$Tl\ h/Q'& &p &&" t0L'644 laTYEEEE$IfgdXlK$kd$IfK$L$Tl\ h/Q'& &p &&" t0L'644 laT(JnYEEEE$IfgdXlK$kd$IfK$L$Tl\ h/Q'& &p &&" t0L'644 laTnpYEEEE$IfgdXlK$kdJ$IfK$L$Tl\ h/Q'& &p &&" t0L'644 laT,@RYEEEE$IfgdXlK$kd $IfK$L$Tl\ h/Q'& &p &&" t0L'644 laT Gall Bladder Disease Measles Stroke Asthma Glaucoma Migraine Headaches Suicide Attempt Bleeding Disorders Goiter Miscarriage Thyroid Problems Breast Lump Gonorrhea Mononucleosis Tonsilitis Bronchitis Gout Multiple Sclerosis Tuberculosis Bulimia Heart Disease Mumps Typhoid Fever Cancer Hepatitis Pacemaker Ulcers Cataracts Hernia Pneumonia Vaginal Infections Venereal Disease Confidential Health History Work Form 5-1 (continued) Hospitalizations Year Hospital Reason for Hospitalization and Outcome Have you ever had a blood transfusion? Yes No If yes, please give approximate dates: OCCUPATIONAL CONCERNS Check {P} if your work exposes you to the following: HEALTH HABITS Check {P} which substances you use and indicate how much you use per day/week. PREGNANCY HISTORY Year of Birth Sex of Birth Complications if any Stress Caffeine Hazardous Substances Tobacco Heavy Lifting Drugs Other Alcohol SERIOUS ILLNESS/INJURIES DATE OUTCOME FAMILY HISTORY Fill in health information about your family. Relation Age State of Health Age of Death Cause of Death Check {P} if your blood relatives had any of the following Disease Relationship to you Father Arthritis, Gout Mother Asthma, Hay Fever Brothers Cancer Chemical Dependency Diabetes Heart Disease, Strokes Sisters High Blood Pressure Kidney Disease Tuberculosis Other I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. 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