Name____________________
D.O.B.___________________
Date_____________________
Please check or circle any symptoms you have or have had:
| | | |
| Gastrointestonal | Neurology | Respiratory |
| | | |
| Abdominal Pain | Alzheimer's | Asthma |
| Blood in Stools | Epilepsy | Bronchitis |
| Diverticulosis | Headaches | Chronic Coughing |
| Hemorrhoids | Multiple Sclerosis | Emphysema |
| Heartburn | Seizures | Pneumonia |
| Frequent Diarrhea | Tremor/Parkinson's | |
| Frequent Constipation | Musculoskelatal | |
| Liver Disease | | |
| | | |
| Endocrine Muscular / Skeletal | Cardiac | Other |
| | | |
| Athritis | Palpitation | Cancer (Type________________) |
| Diabetes | Chest Pain | Anemia |
| Gout | Arrythmia | Prostate Problems |
| Osteoporosis | High Cholesterol | Bleeding Disorders |
| Thyroid (Type_________________________) | High Blood Pressure | Swollen Ankles |
| | Stroke | Glaucoma |
| | | Frequent Urinary Tract Infections |
| | | Depression |
| Renal | | |
| | | |
| Kidney Disease (Type__________________) | | |
Surgeries in the Past (Please list and date)
____________________________________ Date_______________
____________________________________ Date_______________
____________________________________ Date_______________
____________________________________ Date_______________
____________________________________ Date_______________
Medications and Dosage (please list or attach list) ______________________________________ - _________________
______________________________________ - _________________
______________________________________ - _________________
______________________________________ - _________________
______________________________________ - _________________
______________________________________ - _________________
______________________________________ - _________________
______________________________________ - _________________
______________________________________ - _________________
______________________________________ - _________________
Do you smoke? ____ Yes ____No Amount Daily ______________________
Do you Drink? ____ Yes ____No Amount Weekly ____________________
Family Medical History: Medical Illnesses (such as diabetes, heart attack. TB, high blood pressure, stroke, cancer, Alzheimer's Disease, Parkinson's Disease, kidney disease, asthma, arthritis, gout)
Relative - Age - Illness - If deceased, age & cause
Father _____ - ___________________________- _____________________________
Mother ____ - ___________________________- _____________________________
Brother ____ - ___________________________ - _____________________________
Sister ____ - ___________________________ - _____________________________
Children - Name - Date of Birth - If Deceased, Age & Cause
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
