RCAmd.com - New Patient

 

PATIENT MEDICAL HISTORY questionnaire
PATIENT NAME:
DATE:
ADDRESS:
CITY:
TELEPHONE:
DATE OF BIRTH:
AGE:
 
BRIEFLY DESCRIBE YOUR CURRENT MEDICAL PROBLEM:
 
PAST MEDICAL HISTORY YES NO NOT KNOWN
1. HEART DISEASE INCLUDING:  
  A. HEART ATTACK
B. HEART MURMER
C. IRREGULAR HEART BEATS
2. HIGH BLOOD PRESSURE
3. LUNG DISEASE INCLUDING:  
  A. ASTHMA
B. EMPHYSEMA
C. TUBERCULOSIS
4. SCARLET FEVER
5. RHEUMATIC FEVER
6. DIPHTHERIA
7. DIABETES
8. THYROID PROBLEMS
9. SEIZURES (EPILEPSY)
10. ANEMIA OR OTHER BLOOD PROBLEMS
11. KIDNEY OR BLADDER DISEASE
12. ULCER OR STOMACH PROBLEMS
13. ARTHRITIS
14. LIVER DISEASE INCLUDING:  
  A. CIRRHOSIS
B. HEPATITIS
15. GALLBLADDER DISEASE
16. STROKES OR PARALYSIS
17. CANCER
PLEASE LIST ALL SURGERIES AND APPROXIMATE DATE. (INCLUDE TONSILLECTOMY, APPENDECTOMY, ULCER SURGERY, ABORTIONS, D&C, TUBAL LIGATION, VASECTOMY, ETC.)    
PLEASE LIST ALL BROKEN BONES WHICH RESULTED IN YOUR WEARING A CAST AND/OR REQUIRING HOSPITALIZATION.    
PLEASE LIST ALL MEDICATIONS INCLUDING VITAMINS, LAXATIVES, BIRTH CONTROL PILLS, HORMONES, ETC. GIVE STRENGTH OF DOSE (ex. MG) AND NUMBER OF TIMES TAKEN DAILY.    
Do you Smoke ?
Yes No   If Yes, How Much?
Do you Drink Beer, Whiskey, Wine, Etc. ?
Yes No   If Yes, How Much?
ARE YOU ALLERGIC TO ANY MEDICATIONS? ANY FOODS? LIST TYPE AND REACTION.    
FAMILY HISTORY
Is your mother living ?
Yes No   Age:
Is your father living?
Yes No   Age:
How many brothers & sisters do you have?
Brothers: Sisters:
How many are living?
Brothers: Sisters:
Do any of the above have (or had) the following:
  DISEASE Yes No If Yes, Who?
A. HEART TROUBLE
B. HIGH BLOOD PRESSURE
C. LUNG DISEASE
D. ARTHRITIS
E. DIABETES
F. TUBERCULOSIS
G. STROKE OR PARALYSIS
H. CANCER
I. OTHER DISEASE