patient name: date of birth: -...

Patient Name: ____________________________________________ Date of Birth: __________________

Review of Systems – Please Circle any Symptoms that CURRENTLY Apply to you (past/present)

Constitution Eyes Endocrine Allergy/Immunology

Activity Change Eye Discharge Cold Intolerance Environmental Allergies

Appetite Change Eye Itching Heat Intolerance Food Allergies

Chills Eye Pain Very Thirsty Impaired Immune System

Sweating Eye Redness Excessive Hunger

Fatigue Light Sensitivity Urinate Large Volumes

Fever Visual Disturbance

Unexpected Weight Change

HENT Respiratory GU Neurological

Facial Swelling Apnea Difficulty Urinating Dizziness

Neck Swelling Chest Tightness Painful Intercourse Facial Asymmetry

Neck Stiffness Choking Painful Urination Headaches

Ear Discharge Cough Bedwetting Light-Headedness

Hearing Loss Shortness of Breath Flank Pain Numbness

Ear Pain Vibration of Chest Frequent Urination Seizures

Ringing in Ears Wheezing Genital Sore Speech Difficulty

Nosebleeds Blood in Urine Loss of Consciousness

Congestion Cardiovascular Menstrual Problems Tremors

Runny Nose Chest Pain Penile Discharge Weakness

Postnasal Drip Leg Swelling Penile Pain

Sneezing Palpitations Penile Swelling Hematologic

Sinus Pressure Pelvic Pain Enlarged Lymph Nodes

Dental Problem GI Scrotal Swelling Bruises/Bleeds Easily

Drooling Swelling of Abdomen Testicular Pain

Mouth Sores Abdomen Pain Urgent Urination Psychiatric

Sore Throat Anal Bleeding Urine Decreased Agitation

Trouble Swallowing Blood in Stool Vaginal Bleeding Behavior Problems

Constipation Vaginal Discharge Confusion

Skin Diarrhea Vaginal Pain Decreased Concentration

Color Change Nausea Depression

Pale Rectal Pain Musculoskeletal Hallucinations

Rash Vomiting Joint Pain Hyperactive

Wound Back Pain Nervous/Anxious

Problems Walking Self-Injury

Joint Swelling Sleep Disturbance

Muscle Pain Suicidal Ideas

List ALL Providers/Specialist seen:

WHO WHEN WHERE

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PLEASE CHECK THE CORRECT OFFICE

45 Amberwood Parkway, Ashland, OH 44805 558 S.Trimble Rd, Mansfield, OH 44906

770 Balgreen Dr. Ste 203, Mansfield, OH 44906 248 Blymyer Ave, Mansfield, OH 44903

1020 Cricket Ln, Mansfield, OH 44906 375 W. Main St., Lexington, OH 44904

175 W. 4th Street, Mansfield, OH 44906

NAME: ___________________________PREFERRED NAME:______________ DOB: _________/___________/_______

ALIASES: _____________________________________________________ SSN: ________-___________-________

ADDRESS: _____________________________________________________ TELEPHONE NO: ______-_____-_______

GUARDIAN OR RESPONSIBLE PERSON: _______________________________________CELL NO: ______-_____-_______

ALLOWED TO LEAVE VOICEMAIL MESSAGE ON TELEPHONE? YES OR NO

EMAIL: __________________________________________________ LANGUAGE:________________________

RACE: ________________ ETHNICITY: HISPANIC/NOT HISPANIC RELIGIOUS AFFILIATIONS: __________

PLEASE CIRCLE THE APPROPRIATE ANSWER:

GENDER IDENTITY: MALE FEMALE TRANSGENDER MALE TRANSGENDER FEMALE SOMETHING ELSE

SEXUAL STATUS: STRAIGHT HETEROSEXUAL LESBIAN GAY HOMOSEXUAL BISEXUAL OTHER I DON’T KNOW

MARITAL STATUS: SINGLE MARRIED DIVORCED SEPERATED WIDOWED CIVIL UNION LIFE PARTNER POLYGAMUS

SEXUAL ACTIVITY: NOT CURRENTLY YES NO PARTNERS: MALE FEMALE BOTH

PREFERRED TO BE REFERRED TO AS: MALE FEMALE OTHER: ________________________

EMERGENCY CONTACT: ___________________________DOB:______________ TELEPHONE NO: ______-______-________

RELATIONSHIP TO PATIENT: ________________________________

CONTACT ALLOWED TO HAVE MEDICAL/BILLING INFORMATION? YES OR NO

ANY ADDITIONAL PEOPLE ALLOWED TO HAVE MEDICAL/BILLING INFORMATION:

NAME:__________________________DOB:____________TELEPHONE: _______________RELATION___________________

PLEASE BRING COPY WITH YOU TO OFFICE VISIT

NONE DNR (Do Not Resuscitate) LIVING WILL DO NOT PLACE ON LIFE SUPPORT HEALTHCARE PROXY DURABLE POWER OF ATTORNEY

HAVE YOU SERVED IN THE MILITARY? _____________ WHICH BRANCH? __________________________________

EMPLOYER NAME/ADDRESS: _____________________________________________________________________________

STATUS: FULL TIME PART TIME SEASONAL RETIRED STUDENT

WORK TELEPHONE NO: _______-________-_________ OCCUPATION: ______________________________________

Primary Insurance:___________________________________ Policy # _______________________________________ GROUP #__________________________________________ SUBSCRIBER NAME__________________________________ DOB_____________ RELATIONSHIP TO PT________________________________________________________________

SMOKING STATUS: CURRENT EVERY DAY CURRENT SOME DAY HEAVY SMOKER LIGHT SMOKER FORMER SMOKER

NEVER SMOKED PASSIVE SMOKE EXPOSURE-NEVER SMOKED UNKNOWN

TYPES: E-CIGARETTE VAPE CIGARETTECIGAR PIPE CHEW SNUFF

START DATE: _____________________ QUIT DATE: __________________ READY TO QUIT: ______________ COUNSELING GIVEN: _______________

YES NO YES NO

TYPE: ___________________________________________ TYPE: ______________________________________________

COMMENTS: ______________________________________ COMMENTS: ________________________________________

HOW OFTEN: _____________________________________ HOW OFTEN: ________________________________________

NKDA (No known drug allergies) ENVIRONMENTAL SEASONAL

YES (PLEASE LIST)__________________________________________________________________________________________

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DO YOU USE CAFFEINE? YES OR NO AMOUNT OF CAFFEINE PER DAY: __________________________________

CAFFEINE TYPE: COFFEE CHOCOLATE ENERGY DRINK TEA OTHER

DAILY ACTIIVITY LEVEL: MODERATE SEDENTARY VIGOROUS

WHAT TYPE OF EXERCISE DO YOU DO? ________________________________________________________________________

NUMBER OF TIMES PER WEEK: _________________________ NUMBER OF HOURS EXERCISE PER WEEK: __________________

TYPE OF DIET: 1600 CALORIE 1800 CALORIE 2000 CALORIE DIABETIC GLUTEN FREE HEALTHY

HIGH CALORIE HIGH FAT HIGH SALT HIGH ROUGHAGE JUNK FOOD LOW FAT

LOW RESIDUE LOW SALT NO RED MEAT VEGAN VEGATARIAN

PHARMACY NAME: ______________________________________ PHARMACY TELEPHONE: _______-_______-_______

PHARMACY ADDRESS: __________________________________________________________________________________

MEDICATION NAME (BRAND OR GENERIC NAME) MEDICATION STRENGTH/DOSAGE MEDICATION DIRECTIONS

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ANEMIA CHF GERD KIDNEY DISEASE STROKE

ANXIETY CLOTTING DISORDER GLAUCOMA MENINGITIS SUBSTANCE ABUSE

ARTHRITIS COPD HEART MURMUR M.I THYROID DISEASE

ASTHMA DEPRESSION HEPATITIS OSTEOPOROSIS TUBERCULOSIS

CANCER DIABETES HIV/AIDS SEIZURES ULCERS

CATARACTS EMPHYSEMA HYPERTENSION SICKLE CELL ANEMIA

DIAGNOSIS/ DISEASE DATE DIAGNOSED MANAGEMENT OF DIAGNOSIS/DISEASE

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TYPE OF SURGERY DATE OF SURGERY DOCTOR AND FACILITY SURGERY WAS DONE

AT

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BABY #1 DATE OF BIRTH___/___/_____ SEX: MALE OR FEMALE DELIVERY TYPE: _____________________

MISCARRIED: YES OR NO WEIGHT _______LBS LENGTH __________INCHES







PLACE A NUMBER OF PREGNANCIES/DELIVERIES FOR THOSE THAT APPLY:

_______ FULL TERM DELIVERY __________PREMATURE DELIVERY __________CESAREAN DELIVERY

_______VAGINAL DELIVERY (NOT INDUCED) __________VAGINAL DELIVERY (INDUCED) __________LIVING BIRTHS

_______MULTIPLE BIRTHS (TWINS, ETC) ___________ABORTION ___________MISCARRIAGE

AGE OF FIRST MENSTRAL PERIOD: _____________ AGE AT MENOPAUSE: __________________

AGE OF FIRST BIRTH: _______________________ DATE OF LAST PAP: ___________________

DATE OF LAST MENSTRUAL PERIOD: ___________ HORMONE REPLACEMENT THERAPY: YES OR NO

DATE OF LAST MAMMOGRAM: ________________

NAME OF PRIMARY CARE GIVER: ______________________________________________________________

RELATIONSHIP TO PRIMARY CARE GIVER: MOTHER FATHER FOSTER PARENT GRANDPARENT STEP PARENT OTHER

HOW MANY DAYS A WEEK DOES PATIENT SPEND WITH PRIMARY CARE GIVER: _____________________________

SMOKE EXPOSURE: SMOKER AT HOME OUTSIDE SMOKE ONLY NO SMOKE EXPOSURE

HAND DOMINANCE: LEFT RIGHT AMBIDEXTROUS (BOTH HANDS)

DOES PATIENT ATTEND DAY CARE? _________________________ HOW MANY DAYS A WEEK? ___________________

CAR RESTRAINT: CAR SEAT REAR FACE CAR SEAT FRONT FACE BOOSTER SEAT BELT NONE

NUMBER OF SIBLINGS: ________________ BIRTH ORDER: FIRST SECOND THIRD FOURTH FIFTH

HOW MANY HOURS DAILY DOES THE PATIENT: WATCH TV ________ EXERCISE/PLAY SPORTS ________ VIDEO GAME________

CIRCLE ALL THAT APPLIES: TAKES NAPS SLEEPS WITH PARENTS SLEEPS THROUGH THE NIGHT

SLEEPS MINIMUM OF 8.5 HOURS NIGHTLY NIGHTMARES/SLEEP PROBLEMS

LEARNING DISABILITY SPECIAL NEEDS GIFTED PROGRAM LIKES SCHOOL

TRUANCY COLLEGE PREP H.S. GRADUATE

BELOW AVERAGE GRADES AT AVERAGE GRADES ABOVE AVERAGE GRADES

SCREENING MEASURES PROVIDER/LOCATION DATE

Tdap/TD Vaccine

Pneumonia Vaccine

Shingles Vaccine

Colonoscopy/Cologuard

Mammogram

Dexa/Bone Density

PAP/HPV

Low Dose Lung CT

Diabetic Foot/Eye Exam

A1C

Hep C Screening

STATUS PROBLEM AGE ONSET COMMENT

MOTHER

FATHER

SISTER

BROTHER

MGM

PGM

PGF

Adopted Family History Unknown

patient name: date of birth: -...

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