ࡱ> SURY gbjbj[[ 0L9 \9 \LR R 8* I K K K K K K $!x$Ro o  RI I n z`VF 5  0  $a$@ $ o o  $R > : MEDICAL HISTORY Patient Name: ____________________________________________________________ Address: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Date of Birth: ___________________ Telephone Number _____________________ Past Medical History: Circle any of the following that you have had. Allergies or AsthmaCongestive Heart FailureHemorrhoidsMigrainesAlcoholismDepressionHepatitis (Jaundice)PhlebitisAnemiaDiabetesHigh Blood PressurePsoriasisArthritisDrug AbuseHeart BlockageHerniaBreast lumps/cystsEczema-HivesKidney StonesStrokeCancer (Tumors)Epilepsy or SeizuresLiver DiseaseSuicide AttemptCataractsHeart AttackLung DiseaseThyroid Disease Other: __________________________________________________________________ Medications: [List all you are taking, the dosage (strength), and how often you take it.] ____________________________ 4 __________________________ ____________________________ 5 __________________________ ____________________________ 6 __________________________ Drug Allergies: _____________________________________________________ Review of Systems: Within the last 6 months have you had problems withYesNoDescribeGeneral fatigue, weight loss, etc.)Eyes (blurriness, burning, vision, etc.)Ears, Nose, Throat (Drainage, bleeding, hard to swallow, etc.)Lungs or Breathing (Shortness of breath, cough, wheeze, etc.)Heart (chest pains, murmur, skipping, etc.)Bones/Joints (swelling, stiffness, pain, etc.)Skin (rashes, ulcers, etc.)Depression, feeling uptight, sleep problemsGlands (problems with heat/cold, urine, eating, dry skin, hair change) MEDICAL HISTORY Date___________________________ Name: ________________________________ Wt. _______ Ht. ________ Age: _______ Address: ________________________________________________________________________ Phone #: ______________________Are you (circle one) Married Single Divorced Widowed YES NO Have you had any problems with your heart? _____ _____ (Palpitations, murmur, chest pain, heart attack, etc.) Have you had any problems with blood pressure? _____ _____ Have you had any problems with your lungs? _____ _____ (Breathing problems, cough, asthma, emphysema, bronchitis) Do you have a severe cold, cough, nasal congestion or fever now? ______ _____ Do you have diabetes? If yes, how many years? _________________ ______ _____ Do you take insulin injections? ______ _____ Have you had hepatitis, jaundice? ______ _____ Have you had any kidney or bladder problems? ______ _____ Have you received blood transfusions? If so, when? _______________ ______ _____ Have you had convulsions or seizures? ______ _____ Have you had psychiatric problems? ______ _____ Any back problems? ______ _____ Have you had any problems with anemia? ______ _____ Have you had any problems with excessive bleeding? ______ _____ Have you had a history of stomach ulcers/hiatal hernia/indigestion? ______ _____ Do you have loose teeth, dentures, caps, or crowns? (If yes, please circle) ______ _____ Do you smoke? If so, how many packs a day? ____ ______ _____ How many years? ___ Do you drink alcohol? If so, how much? __________________________ ______ _____ Any muscle disease in your family? (Muscular Dystrophy, Multiple Sclerosis, etc.) ______ _____ Some Medical Problems in English and Spanish Allergies or Asthma = alergias o asma Alcoholism = alcoholismo Anemia = anemia Breast lumps/cysts = tumor o quiste de seno Cancer (tumors) = cancer (tumores) Cataracts = cataratas Congestive Heart Failure = fracaso congestivo Del corazn Depression = depresin Diabetes = diabetes Drug Abuse = abuso de drogas Eczema-Hives = eczema-ronchas Epilepsy or Seizures = epilepsia o ataque Heart Attack = ataque al corazn Hemorrhoids = hemorroides Hepatitis (Jaundice) = hepatitis High Blood Pressure = presin Alta Heart Blockage = bloqueo Del corazn Kidney Stones = piedras en el rin Liver Disease = enfermedad Del hgado Lung Disease = enfermedad Del pulmn Migraines = migraas Phlebitis = flebitis Psoriasis = soriasis Hernia = hernia Stroke = infarto Suicide Attempt = intento de suicidio Thyroid Disease = enfermedad de la tiroides     PAGE  \  5 9 E  T ,U^ox/_bKLMOPRSUVXY۾۾۾۾ۺۺۺ۳ۤۤۤۤۚjh~/0JUjh~/U h~/5CJ( h5CJ(h h~/5 hCJ h~/>* h~/5CJ h~/CJh~/ h~/5CJhh~/5>*CJ  *hh~/5>*CJ <\]1 2   $If$a$$a$gd   % : D lffff$Ifkd$$Ifl\l" b04 laD E L U i s lffff$Ifkd$$Ifl\l" b04 las t ~ lffff$Ifkd<$$Ifl\l" b04 la lffff$Ifkd$$Ifl\l" b04 la  lffff$Ifkdx$$Ifl\l" b04 la  $ 1 > N lffff$Ifkd$$Ifl\l" b04 laN O P 0 k  ljjjjeeejjc & Fkd$$Ifl\l" b04 la  5 9 < E F j k l TNNN$IfkdR$$Ifl\:d4(#* 04 la$If $$Ifa$ $$Ifa$l m n fkd$$Ifl\:d4(#* 04 la$If lfffff$Ifkd$$Ifl\:d4(#* 04 la lfffff$Ifkd,$$Ifl\:d4(#* 04 la LMNOlffff$Ifkd$$Ifl\:d4(#* 04 laOPlffff$Ifkdh$$Ifl\:d4(#* 04 lalffff$Ifkd$$Ifl\:d4(#* 04 lalffff$Ifkd$$Ifl\:d4(#* 04 lalffff$IfkdB $$Ifl\:d4(#* 04 la012RSTljeeeeeecjj$a$kd $$Ifl\:d4(#* 04 la STUo23w gh-.`h`h & F &dP ?@./PQt$a$ 8X^8`Xh`h & F/@l.MwCj ^`^^KLNOQRTUWXabcdefg$h]ha$h]h&`#$^Y_`afgh~/jh~/0JU h~/0J.:p/ =!"#$% $$If!vh#v#v #v#vb:V l055 55b4$$If!vh#v#v #v#vb:V l055 55b4$$If!vh#v#v #v#vb:V l055 55b4$$If!vh#v#v #v#vb:V l055 55b4$$If!vh#v#v #v#vb:V l055 55b4$$If!vh#v#v #v#vb:V l055 55b4$$If!vh#v#v #v#vb:V l055 55b4$$If!vh#v#v*#v#v :V l055*55 4$$If!vh#v#v*#v#v :V l055*55 4$$If!vh#v#v*#v#v :V l055*55 4$$If!vh#v#v*#v#v :V l055*55 4$$If!vh#v#v*#v#v :V l055*55 4$$If!vh#v#v*#v#v :V l055*55 4$$If!vh#v#v*#v#v :V l055*55 4$$If!vh#v#v*#v#v :V l055*55 4$$If!vh#v#v*#v#v :V l055*55 4$$If!vh#v#v*#v#v :V l055*55 4s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH 8`8 Normal_HmH sH tH 8@8  Heading 1$@&5D@D  Heading 2$$@&a$ 5>*CJ@@@  Heading 3$@&^CJDA`D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k ( 0No List 6U6  Hyperlink >*B*ph4>@4 Title$a$5CJ0J@0 SubtitleCJ4"4 Header  !4 @24 Footer  !.)@A.  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