Name: ________________________________________________ Date of Birth: _______________________
Major Medical Concerns
Describe briefly, the major medical problem(s) or question(s) for which you are seeking attention:
___________________________________________________________________________________________
Current Height: ______________
Angina/Heart Pain Heart Attack Heart Failure High Blood Pressure Irregular Heartbeat Anxiety/Nerves Mental Illness Depression Asthma Emphysema/Bronchitis Pneumonia Tuberculosis Colitis/Bowel Problems
Current Weight: _____________
Gallstones Ulcers (GI Tract) Liver Disease/Hepatitis Drinking Problem Blood Clots Sickle Cell Disease Blood Disorder/Anemia Kidney Disease/Stones Prostate Disease Urine Infections Migraines/Headaches Epilepsy/Seizures Stroke
Usual Weight: ___________
Dementia/Alzheimer's D's Cataracts Diabetes/Sugar Glaucoma Thyroid Problem/Goiter Fibrocystic Breast Disease Cancer Arthritis/Rheumatism Eczema/Rash Ulcers (Skin) Psoriasis Other _________________ Other _________________ Other _________________ Other _________________
Appendix Hemorrhoids Breast Hernia Colon/Intestinal Hysterectomy Gall Bladder Tonsils/Adenoids Heart Other ___________________________________________________
Other ___________________________________________________
Obstetrical/Gynecological for Women:
PREGNANCIES DELIVERIES
Live births ________ cesarean sections________
Miscarriages/still births ________ PREVENTATIVE CARE
Abortions ________ Last Mammogram _________
MENSTRUATIONAre you having hot flashes?
yes no
Have you completed menopause? yes no
PLEASE COMPLETE ALL FOUR PARTS OF THIS FORM AND BRING TO YOUR NEXT VISIT
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GENERAL MEDICAL QUESTIONNAIRE
Medical (please check all that apply)Past Health History
Surgical (Please check all that apply):
Last Papsmear _________
