ࡱ>  bjbjUU 4??HO  OOOOOccc8|c/"***.......1G4V.O*|&***.OOi.\-\-\-*OO.\-*.\-\-\-@%/;c:+^\-..0/\-4+Z4\-4O\-**\-*****..,j***/****4*********  :  Anne Coleman, M.D., P.A. Patient History (Please Print) Name____AgeDateYou may make additional comments or attach separate sheets where needed. Please be sure to write your name at the top of EACH page. What are the main reasons for your visit to our office? 1. 2. 3. How or why did you select our office to address your concerns? REVIEW OF SYSTEMS Please complete the following by placing aaby any symptom that you have experienced in the past year.1. General/Constitutional8. Genitourinaryo Weight Losso Weight Gaino Poor Appetiteo Fevero Frequent Urinationo Painful Urinationo Sweatso Loss of Sleepo Can t Fall Asleepo Nervousnesso Lack of Bladder Controlo Blood in Urine 2. Eyes9. Musculoskeletal (symptoms of pain/weakness)o Blurred Visiono Crossed Eyeso Double Visiono Vision - Haloso Arms o Backo Feeto Handso Vision - Flasheso Hipso Legso Shoulders 3. Ear, Nose, Mouth, and Throat10. Skino Bleeding Gumso Earacheo Ear Dischargeo Hay Fevero Bruise Easily o Hiveso Itching o Change in Moles o Loss of Hearingo Nosebleedso Sinus Problemso Ringing in Earso Rasho Scars o Sores That Won t Heal 4. Neck11. Neurologicalo Tightnesso Lump in Throato Difficulty Swallowingo Dizzinesso Vertigoo Faintingo Numbnesso Hoarsenesso Headacheso Migraines  5. Cardiovascular12. Psychologicalo Chest Paino Palpitationso Poor Circulationo Swollen Ankleso Depressiono Anxietyo Insomniao Rapid Heart Rateo Varicose Veinso Irregular Heart Beat13. Endocrine 6. Respiratoryo Excess Hungero Excess Thirsto Shortness of Breatho Wheezing14. Heme/Lymphatic 7. Gastrointestinalo Easy Bleedingo Swollen Lymph Nodeso Bloating/Gaso Bowel Changeso Constipationo Diarrhea15. Allergic/Immuneo Hemorrhoidso Rectal Bleedingo Nausea/Vomitingo Vomiting Bloodo Hay Fevero Hiveso Rasho Stomach Paino Indigestion/HeartburnList names and specialties of all physician seen in the last year.    * * * * * Name _____ Date Page 2 Men Onlyo Erection Difficultieso Lump in Testicleso Penis Dischargeo Sore on PenisNumber of ChildrenFemale Onlyo Bleeding Between Periodso Breast Lumpo Severe Menstrual Paino Hot Flasheso Night Sweatso Nipple Dischargeo Painful Intercourseo Vaginal Discharge SHAPE \* MERGEFORMAT  Date of Last PeriodDate of Last PAP Smear o Normal o AbnormalDate of Last MammogramPregnant? o Yes o No o MaybeNumber of PregnanciesNumber of TerminationsNumber of ChildrenAny Complications?Fertility Treatments?MEDICAL HISTORY Please complete the following by placing aaby any illness that applies and the year of onset or diagnosis. o AIDS/HIV Positiveo CODPo Liver Diseaseo Alcoholismo Diabeteso Migraine Headacheo Anorexiao Depressiono Miscarriageo Appendicitiso Arthritiso Mononucleosiso Arrthymia / Irregular Heartbeato Emphysemao Multiple Sclerosiso Arthritiso Endocrine / Glandular Diseaseo Osteoporosiso Asthma Specify Above: o Pacemaker Date Inserted:o Bleeding Disorderso Epilepsyo Pneumoniao Blood Transfusiono Fibromyalgiao Polioo Breast Lumpo Thyroid Goitero Prostate Problemo Bronchitiso Gonorrheao Rheumatic / Scarlet Fevero Bulimiao Gouto S 0?@AFGHLMNOSTUZ[\   }llg\gNDh(]CJOJQJjh(]UmHnHuh(]5CJOJQJ h(]5!jh(]5PJUmHnHu h(PJh(]5OJPJQJ h(]PJjh(]PJUmHnHu h(]CJh(]5OJQJh(]5:CJOJQJ,jh(]5:CJOJQJUmHnHuh(]5:OJQJh(]5:CJOJQJaJh*5:CJOJQJaJ0?@FGMNSTZ[x$If$IfP$If$xa$$a$ [\kd$$Ifl4ִ8$ "*N TJ%m0+    44 laf4\  ! $ & ' f j bkd^$$Ifl *064 la$If$If$(xa$   $ % ' f i k  x z  * , 0 : < > @ d f h j ޷ޮޟ}si}si`}s}h(]mHnHuh(]CJOJQJh(]CJOJQJh(]@CJOJQJaJh(]5CJmHnHu h(]5CJh(]5@CJOJQJaJh(]5OJQJh(]5CJEHOJQJaJ h(]:CJh(]fHq h(]5h(]h(]CJOJQJ%jh(]5OJQJUmHnHu%j k x ($Ifqkd$$Ifl8*  064 lap x z ($Ifqkd$$Ifl*  064 lap  , < f l\\\\LLGFfG($If]^($If]^kdO$$Ifl4(0d*   064 laf4p  : \ ^ r ($IfFfc ($If]^   8 : < > Z \ ^    8 : < Z ^ h j n v x | ʿٶٶٶٶh(]CJOJQJh(]5CJOJQJh(]5aJmHnHuh(]5CJaJh(]5CJOJQJ h(]5h(]CJOJQJh(]5@CJOJQJaJh(]@CJOJQJaJh(]CJOJQJ8  8 Z j x l\\\\PPPP ($If^($If]^kdw $$Ifl4 0d*   064 laf4p >RFf ($If^($If]^Ff <>PRTVXtvx ,.024TVXnpr<@BDXZ\z|~ʻʻʻʻʻʻʻʻʻʻʻʻh(]5mHnHuh(]5@CJOJQJaJh(]@CJOJQJaJh(]5CJOJQJh(]CJOJQJh(]5CJOJQJ h(]5CJERTtl\\\\PPP ($If^($If]^kd$$Ifl4 0d*   064 laf4p.0Tn> ($If^Ffm ($If^($If]^Ffp($If]p^ >@Xzl\\\PPPP ($If^($If]^kd!$$Ifl4 0d*   064 laf4p$&(<>@Z\  ,.0FHJZ\^rtvx *,.0LNPprtvٹh(]CJOJQJh(]5CJOJQJh(]5CJOJQJh(]CJOJQJh(]5@CJOJQJaJh(]@CJOJQJaJI "$<VXZ\Ff) ($If^($If]^Ff %  ,FZprl\\\\PPPP ($If^($If]^kdc,$$Ifl4 0d*   064 laf4p rt ($If^($If]^p($If]p^Ff/ ,0 p($If]p^kd[2$$Ifl4 \2 d*hh  (064 laf4p(,Llnp ($If^prkd3$$Ifl4 rd O%* hiih 2064 laf4p2r$If ($If^($If]^  ,.0Z\^`xz|~8:<>\^`b~ܸƸܸܸܸƸܸܸܸܸƸ歸h(]5CJOJQJh(]@CJOJQJaJh(]5CJOJQJh(]5CJOJQJh(]CJOJQJh(]CJOJQJh(]5@CJOJQJaJD 0 ($If]^kd5$$Ifl4 \2 dO%*:h (064 laf4p( ,XZ\$kdS7$$Ifl4 \dO%* hh (064 laf4p( ($If^\z ($If^($If]^kd8$$Ifl4 r2 d*hhh  2064 laf4p2:^($IfFf9= ($If^($If]^ IJKMNOPWenops.04VX\z|Ƚ뗓ytytytytcyt\ h#Vh(]!jh(]5CJUmHnHu h(]5 h(]5CJh(]5@CJOJQJaJh(h(]jh(]UmHnHuh5CJ$OJQJaJ$h5CJOJQJh(5CJOJQJjh(]5UmHnHuh(]CJOJQJhquNCJOJQJh(]5CJOJQJh(]CJOJQJ#JL0&!dh $dhPa$kd?$$Ifl4 \d*hh  (064 laf4p(LMOXp0X|wkkkkk ($If^skdoA$$Ifl4 *+  0+4 laf4p $($Ifa$dhdh O@$($If^a$kd"B$$Ifl4 r/e"*0+4 laf4026`bf|~JNPTVXZ  "$PTfnrv  02VXԹԹٮԹԹh(]5CJOJQJ!jh(]5CJUmHnHujh(]5U h(]5 h(]5CJh(]5@CJOJQJaJh(]h#Vh(]CJOJQJD2b~ ($If^skdC$$Ifl4 *+  0+4 laf4p VOCCCCC ($If^kdC$$Ifl4 r/e"*0+4 laf4VX"ROC4C$P$If^a$ P$If^kdD$$Ifl4 r/e"*0+4 laf4RTuiii P$If^kdE$$Ifl4 F@ * V 0+    4 laf4 2Xui[iPx$If^ P$If^kdF$$Ifl4 F D*XXX0+    4 laf4X 48<LNRfhl "&8:>bfj|~   P T X | ¸¸¸¸¸°h(]OJQJh(]CJOJQJh(]CJOJQJh(]@CJOJQJaJh(]5CJEHOJQJaJh(] h(]CJ h(]5 h(]5CJEunbbb ($If^dhkdG$$Ifl4 F D*XXX0+    4 laf46VJJJ ($If^kdsH$$Ifl F D*XXX 06    4 lap68Nh|ppp ($If^kdI$$Ifl F D*XXX06    4 laVJJJ ($If^kdTJ$$Ifl F D*XXX 06    4 lap":d|ppp ($If^kdjK$$Ifl F D*XXX06    4 ladf~VJJJ ($If^kd5L$$Ifl F D*XXX 06    4 lap R |ppp ($If^kdKM$$Ifl F D*XXX06    4 laR T ~ VJJJ ($If^kdN$$Ifl F D*XXX 06    4 lap| ~ !! ! !"!&!B!D!H!h!l!p!!!!!!!!!!!!!!!!" >@DprvĎ048JLP\^bz~Uh(]h(]CJOJQJh(]@CJOJQJaJh(]CJOJQJU !|ppp ($If^kd,O$$Ifl F D*XXX06    4 la!!"!D!j!VJJJ ($If^kdO$$Ifl F D*XXX 06    4 lapj!l!!!!|ppp ($If^kd Q$$Ifl F D*XXX06    4 la!!!! VJJJ ($If^kdQ$$Ifl F D*XXX 06    4 laptrokeo Cancer (specify below)o Heart Disease / Murmuro Suicide Attempt Type:o Hepatitiso Thyroid Problemso Candidiasiso Herniao Tonsillitiso Cataractso Herpeso Tuberculosiso Chemical Dependencyo High Cholesterolo Ulcerso Claudicationo High Blood Pressureo Urinary Tract / Bladder Infectionso Congestive Heart Failureo Kidney Diseaseo Vaginal InfectionsAdditional Comments or Illnesses Not Mentioned SURGICAL HISTORY Please list hospitalizations or surgeries with dates below. DateHospitalization or Surgical ProcedureDateHospitalization or Surgical Procedure Do you have a will? o Yes o No * * * * * Name _____ Date Page 3 ALLERGIES Please list below. Medication AllergiesOther AllergiesINTERVENTIONS / DISEASE SCREENS Please aaby any that apply and the year of most recent. o Tetanus Boostero Flex Sigo Cholesterol Testo Flu Shoto Colonoscopyo Sonogramo ECGo Upper GIo MRI / CT Scano Stool Test for Bloodo Mammogramo Complete Lab WorkLIFESTYLE Please answer questions below. Tobacco (If you have never used tobacco, skip to alcohol section below)1. Types?2. How often / how much?3. How many years?4. Interested in quitting? What have you tried? Alcohol (If you have never used alcohol, skip to caffeine section below)1. How often / how much?2. How many years?3. Ever feel it s a problem?4. Ever drink and drive?Caffeine (If you never use caffeine, skip this question)1. How many servings per day?2. What types of caffeine drinks?3. Other types of caffeine?SOCIAL HISTORY Please answer questions below. Marital Statuso Singleo Marriedo Divorcedo Widowedo Separatedo Living with PartnerWhat activity predominates your workday?What is your highest level of education?Do you exercise? How often and what types of exercise?How would you describe your diet? 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