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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