Confidential Health History
|Confidential Health History |
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|Name: Date: |
|Birthdate: Age: Date of last physical examination: |
|Occupation: |
|Reason for visit today: |
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|Medications List all medications you are currently taking |
|Allergies List all allergies |
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|Symptoms Check {Π} symptoms you currently have had in the past year. |
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|General |
|Gastrointestinal |
|Eye, Ear, Nose, Throat |
|MEN only |
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|≤ Chills |
|≤ Appetite poor |
|≤ Bleeding gums |
|≤ Breast lump |
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|≤ Depression |
|≤ Bloating |
|≤ Blurred vision |
|≤ Erection difficulties |
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|≤ Dizziness |
|≤ Bowel changes |
|≤ Crossed eyes |
|≤ Lump in testicles |
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|≤ Fainting |
|≤ Constipation |
|≤ Difficulty swallowing |
|≤ Penis discharge |
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|≤ Fever |
|≤ Diarrhea |
|≤ Double vision |
|≤ Sore on penis |
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|≤ Forgetfulness |
|≤ Excessive hunger |
|≤ Earache |
|≤ Other |
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|≤ Headache |
|≤ Excessive thirst |
|≤ Ear discharge |
|WOMEN only |
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|≤ Loss of sleep |
|≤ Gas |
|≤ Hay fever |
|≤ Abnormal Pap Smear |
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|≤ Loss of weight |
|≤ Hemorrhoids |
|≤ Hoarseness |
|≤ Bleeding between periods |
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|≤ Nervousness |
|≤ Indigestion |
|≤ Loss of hearing |
|≤ Breast lump |
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|≤ Numbness |
|≤ Nausea |
|≤ Nosebleeds |
|≤ Extreme menstrual pain |
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|≤ Sweats |
|≤ Rectal bleeding |
|≤ Persistent cough |
|≤ Hot flashes |
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|Muscle/Joint/Bone |
|Pain, weakness, numbness in: |
|≤ Stomach pain |
|≤ Ringing in ears |
|≤ Nipple discharge |
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|≤ Vomiting |
|≤ Sinus problems |
|≤ Painful intercourse |
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|≤ Arms |
|≤ Hips |
|≤ Vomiting blood |
|≤ Vision – Flashes |
|≤ Vaginal discharge |
|≤ Other |
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|Date of last |
|menstrual period |
|Date of last |
|Pap Smear |
|Have you had |
|a mammogram? |
|Are you pregnant? |
|Number of children |
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|≤ Back |
|≤ Legs |
|Cardiovascular |
|≤ Vision – Halos |
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|≤ Feet |
|≤ Neck |
|≤ Chest pain |
|Skin |
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|≤ Hands |
|≤ Shoulders |
|≤ High blood pressure |
|≤ Bruise easily |
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|Genito-Urinary |
|≤ Irregular heart beat |
|≤ Hives |
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|≤ Blood in urine |
|≤ Low blood pressure |
|≤ Itching |
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|≤ Frequent urination |
|≤ Poor circulation |
|≤ Change in moles |
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|≤ Lack of bladder control |
|≤ Rapid heart beat |
|≤ Rash |
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|≤ Painful urination |
|≤ Swelling of ankles |
|≤ Scars |
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|≤ Varicose veins |
|≤ Sores that won’t heal |
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|Medical History Check {Π} the medical conditions you have or have had in the past. |
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|≤ AIDS |
|≤ Chemical dependency |
|≤ Herpes |
|≤ Polio |
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|≤ Alcoholism |
|≤ Chicken Pox |
|≤ High Cholesterol |
|≤ Prostate Problem |
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|≤ Anemia |
|≤ Diabetes |
|≤ HIV Positive |
|≤ Psychiatric Care |
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|≤ Anorexia |
|≤ Emphysema |
|≤ Kidney Disease |
|≤ Rheumatic Fever |
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|≤ Appendicitis |
|≤ Epilepsy |
|≤ Liver Disease |
|≤ Scarlet Fever |
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|≤ Arthritis |
|≤ Gall Bladder Disease |
|≤ Measles |
|≤ Stroke |
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|≤ Asthma |
|≤ Glaucoma |
|≤ Migraine Headaches |
|≤ Suicide Attempt |
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|≤ Bleeding Disorders |
|≤ Goiter |
|≤ Miscarriage |
|≤ Thyroid Problems |
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|≤ Breast Lump |
|≤ Gonorrhea |
|≤ Mononucleosis |
|≤ Tonsilitis |
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|≤ Bronchitis |
|≤ Gout |
|≤ Multiple Sclerosis |
|≤ Tuberculosis |
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|≤ Bulimia |
|≤ Heart Disease |
|≤ Mumps |
|≤ Typhoid Fever |
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|≤ Cancer |
|≤ Hepatitis |
|≤ Pacemaker |
|≤ Ulcers |
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|≤ Cataracts |
|≤ Hernia |
|≤ Pneumonia |
|≤ Vaginal Infections |
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|≤ Venereal Disease |
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|Confidential Health History |
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Work Form 5-1 (continued)
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|Hospitalizations |
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|Year |
|Hospital |
|Reason for Hospitalization and Outcome |
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|Have you ever had a blood transfusion? ≤ Yes ≤ No |
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|If yes, please give approximate dates: |
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|OCCUPATIONAL CONCERNS |
|Check {Π} if your work exposes you |
|to the following: |
|HEALTH HABITS Check {Π} which substances you use and indicate how much you use per day/week. |
|PREGNANCY HISTORY |
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|Year of Birth |
|Sex of Birth |
|Complications if any |
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|≤ Stress |
|≤ Caffeine |
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|≤ Hazardous Substances |
|≤ Tobacco |
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|≤ Heavy Lifting |
|≤ Drugs |
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|≤ Other |
|≤ Alcohol |
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|SERIOUS ILLNESS/INJURIES |
|DATE |
|OUTCOME |
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|FAMILY HISTORY Fill in health information about your family. |
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|Relation |
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|Age |
|State of Health |
|Age of Death |
|Cause of Death |
|Check {Π} if your blood relatives had any of the following |
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|Disease |
|Relationship to you |
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|Father |
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|≤ Arthritis, Gout |
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|Mother |
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|≤ Asthma, Hay Fever |
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|Brothers |
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|≤ Cancer |
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|≤ Chemical Dependency |
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|≤ Diabetes |
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|≤ Heart Disease, Strokes |
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|Sisters |
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|≤ High Blood Pressure |
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|≤ Kidney Disease |
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|≤ Tuberculosis |
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|≤ Other |
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|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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|Signature Date |
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|Reviewed By Date |
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