Clinical History.

Name ______________________________________________________

Permanent Address ______________________________________________________

______________________________________________________

Emergency Contact No. ___________________________________________________

Date of Birth (dd/mm/yy)_________________ Age_________________________

Height (cms) ________________________ Weight (kgs.) _______________

Blood Group _________________

No. of Family Members ________________________________________________

Family History – Kindly indicate below if any family member is suffering from any of the following and mention the relationship with you:

1. Diabetes _________________________________________________________

2. Mellitus _________________________________________________________

3. Hypertension _____________________________________________________

4. Asthma __________________________________________________________

5. Epilepsy __________________________________________________________

6. Heart Problems ___________________________________________________

7. Joint Problems ____________________________________________________

Personal History – Kindly indicate below if you are suffering from

1. Diabetes _________________________________________________________

2. Mellitus _________________________________________________________

3. Hypertension _____________________________________________________

4. Asthma __________________________________________________________

5. Epilepsy _________________________________________________________

6. Tuberculosis _____________________________________________________

7. Smoking/Drinking ________________________________________________

8. Heart Problem____________________________________________________

9. Allergy to a known item ___________________________________________

10. Any known disease _______________________________________________

PHYSICAL HISTORY

Have you been diagnosed with or have you ever experienced any of the following conditions?

Endocrinology                                                                            Y N

Type I Diabetes (Insulin dependant)

Type II Diabetes (Non-Insulin dependant)

Hyperthyroid

Hypothyroid

Goiter

Grave’s Disease

Neurological

Numbness or tingling in the hands or feet

Seizures

Epilepsy

Multiple Sclerosis (MS)

Skin

Dermatitis

Rashes

Open sores

Psoriasis

Hematology

Blood clots from an injury or accident

Anemia

DVT (Deep Vein Thrombosis/Active Thrombophlebitis in legs)

Thrombocytopenia – low platelets; bleeding problems

Heparin exposure

Coumadin use

Iron supplements

Hemophilia

OB/GYN

Hormone replacement

Birth Control Pill/Patch

Irregular periods

Difficulty in conceiving

Excessively painful periods

Gastrointestinal

GERD

Heartburn

Stomach (peptic ulcer)
Duodenal ulcer
Constipation
Diarrhea
Vomiting
Colitis
Irritable Bowel Syndrome
Crohn’s Disease

Gallbladder Disease

Gallstones (Cholelithiasis)

Are you symptomatic?_________________________________

Inflammation/infection of gallbladder (Cholecystitis)

 Respiratory

Asthma
Chronic Bronchitis
Sleep Apnea
Sleep Apnea treated C-Pap/Bi-Pap
Shortness of breath on exertion
COPD (Chronic Obstructive Pulmonary Disease)
Emphysema

Cardiovascular

Heart Attack (Myocardial Infarction)
Angina
Palpitations
High Blood Pressure (Hypertension)
Stroke (CVS)
Mini-Stroke (TIA)
Chest Pain
Heaviness in chest
Congestive heart failure
Peripheral vascular disease
High cholesterol
 
Infectious Disease                                 Y N
Hepatitis A
Hepatitis B
Hepatitis C
HIV Positive
Liver Disease
 
Genital-Urinary
Recurrent urinary infection
Kidney stones
Kidney disease
Renal/Kidney failure (dialysis)
Gout
Stress incontinence
 
Musculoskeletal
Arthritis
Back pain
Migraine headaches (describe): __________________________________
Pain in weight bearing joints

Psychological
Depression: Medication: _______________________________________
Bi-Polar Disorder
Anxiety
Suicide attempt
Anorexia
Bulimia
Cancer
Lung
Breast
Prostate
Colon
Lymphoma
Other:______________________________________________________

Provide any pertinent information which you feel will help the doctor in treating you.

Medications:

List all prescription medications taken currently on a regular basis:
Do you take aspirin on a regular basis? Yes___ No____
Brand ______________________ Dosage _______________________ 

Medication	Dosage	Frequency	Date started	Rason for taking	Ordering Physician

Are any of the above medications taken for hormone replacement or birth control? Yes No

PAST SURGICAL HISTORY:

Operation/Procedure	Reason	Date	Hospital

PRIOR SURGICAL PROBLEMS:

Describe all problems	Date	Hospital
Anesthesia:
Wound:
Bleeding:
Clotting:
Fever:
Other:

SIGNIFICANT FAMILY HISTORY:

Check any family member who has suffered or experienced any of the following conditions

M=Maternal P=Paternal

                                                                              Grandmother Grandfather Aunt(s) Uncle(s)

Mother Father Sister(s) Brother(s)  M P           M P                M P        M P

Hypertension

Diabetes

Arthritis

Cardiac disease

Stroke

Lung disease

Cancer

Obesity

Liver disease

Early death

DVT blood clots

PAST MAJOR MEDICAL HISTORY:

Major	Illness	Date	Treatment	Physician

GENERAL HISTORY:

Do you smoke? Yes_______ No_______

Frequency/Amount per day and # of years:____________________________________
Do you drink alcohol? Yes___ No___
Frequency/Amount:______________________________________________________
Check if you use any of the following? Wheelchair___ Walker____ Oxygen_____
Do you use any drugs (non-prescription/over the counter/illicit? Yes__ No___

Drug	Frequency

ALLERGIES:

Are you allergic to any medication: Yes____ No_____

Medication	Reaction

 Are you allergic to any foods? (dairy, wheat products, shellfish) Yes No

List:


Are you allergic to any materials? (latex, surgical tape, wool, iodine) Yes No
List:

What was the date of your last physical examination?_____________________________________

Significant findings:_____________  Date: ______________