MEDICATION ALLERGIES (WHAT REACTION DID YOU HAVE TO EACH DRUG? DIABETES THYROID CANCER ULCERS/REFLUX IRRITABLE BOWEL COLITIS/CROHN’S LIVER …
NAME _______________________________________BIRTHDATE__________TODAYS
DATE_________
OPERATIONS OR PROCEDURES: LIST DATE AND TYPE OF PROCEDURE SUCH AS
TONSILS, APPENDIX, GALLBLADDER, CESAREAN, CHILDBIRTH, ANGIOGRAM
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_____________
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MEDICATION ALLERGIES WHAT REACTION DID YOU HAVE TO EACH DRUG?:
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REACTION TO ANESTHESIA?
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DO YOU HAVE A LIVING WILL/HEALTH CARE POWER OF ATTORNEY? Y N
CIRCLE ANY OF THE FOLLOWING YOU HAVE HAD:
ADULT DISEASES
ALLERGIES ASTHMA BRONCHITIS EMPHYSEMA
HIGH CHOLESTEROL HYPERTENSION HEART DISEASE STROKE/TIA
DIABETES THYROID CANCER ULCERS/REFLUX IRRITABLE BOWEL
COLITIS/CROHNS LIVER DISEASE GALLBLADDER KIDNEY STONES
KIDNEY
FAILURE PROSTATE INCONTINENCE
BREAST PROBLEMS OVARIAN CYSTS ENDOMETRIOSIS FIBROIDS
SEIZURES MIGRAINES HEAD INJURY SKIN DISORDER DEPRESSION
ANXIETY OTHER PSYCH CATARACTS GLAUCOMA HEARING LOSS
ARTHRITIS FIBROMYALGIA
ANEMIA BLOOD CLOTS BLEEDING TRANSFUSION
INFECTIOUS DISEASES
CHICKEN POX MEASLES RUBELLA GERMAN MEASLES
TUBERCULOSIS POLIO WHOOPING COUGH
MUMPS MENINGITIS MONONUCLEOSIS PNEUMONIA
RHEUMATIC FEVER SCARLET FEVER STREP THROAT HIV AIDS
HEPATITIS: A B C GONORRHEA CHLAMYDIA SYPHILIS
PERSONAL BACKGROUND AND OCCUPATION
COUNTRY OF BIRTH __________________________YEARS IN
US__________________________
OCCUPATION_________________________________ETHNICITY/RACE______________
________
MARITAL STATUS_____________________________NUMBER OF
CHILDREN________________
SPOUSE/PARTNER
NAME_____________________________________________________________
CHILDRENS NAMES BIRTH YEARS:
_______________________________________________________________________
_______________________________________________________________________
__________________________
WHO LIVES WITH
YOU?___________________________ WHAT
PETS?______________________
OCCUPATIONAL EXPOSURE: TRAVEL____LIFTING_____ DUST____FUMES
____NOISE_____ CHEMICALS OR DYES ___KEYBOARDING___ REPETITIVE
MOTION_____ METALS LEAD, MERCURY, OTHER___ ASBESTOS____ FARMING____
ANIMALS___OUTDOOR WORK_____ STRESS AT WORK______
HOBBIES________________________________________________________________
___________
RELIGIOUS BELIEFS _______________________________SPECIAL
DIET?___________________
HISTORY OF MILITARY
SERVICE?_____________________WHERE?_______________________
PERSONAL HABITS
TOBACCO USE: HAVE YOU EVER SMOKED? Y N HOW
MUCH?________________________
HAVE YOU QUIT? _________WHAT YEAR?_________ CHEW TOBACCO?
___________________
ALCOHOL: DO YOU DRINK ALCOHOL? _____HOW
OFTEN?______________________________
HOW MUCH TYPE AND
AMOUNT____________________________________________________
HAVE YOU BEEN TREATED FOR ALCOHOL
PROBLEMS?________________________________
ARE YOU CONCERNED ABOUT YOUR DRINKING OR DRUG
USE?________________________
ILLEGAL DRUGS: HAVE YOU EVER USED?_______IF SO, WHAT?
_______________________ INJECTABLE
IV
DRUGS?____________________________________________________________
CAFFEINE: DO YOU DRINK COFFEE, TEA,
COLAS?______WHAT?________________________
HOW MUCH/HOW MANY PER
DAY?___________________________________________________
EXERCISE: DO YOU EXERCISE
REGULARLY?__________________WHAT?_________________
HOW OFTEN?_____________FOR HOW LONG?__________
SEXUALITY: APPROXIMATE NUMBER OF PARTNERS DURING
LIFE?_____________________
PARTNERS ARE/HAVE BEEN
MALE__________FEMALE__________BOTH__________________
ARE YOU CURRENTLY IN A RELATIONSHIP?________DO YOU FEEL SAFE WITH THIS
PARTNER? ________HAVE YOU BEEN HIT/KICKED BY
HIM/HER?_________________________
FAMILY HISTORY
PLEASE CIRCLE ANY ILLNESSES THAT PARENTS, SIBLINGS, CHILDREN, AUNTS,
UNCLES, OR GRANDPARENTS HAVE HAD WRITE IN THE BLANK WHICH RELATIVES
HAVE BEEN AFFECTED
UNKNOWN–ADOPTED ______________INTEREST IN LOCATING BIRTH
FAMILY?___________
CANCER TYPE?_____________________ HEART
ATTACK________________________
STROKE____________________________ HIGH BLOOD
PRESSURE________________
DIABETES__________________________ HIGH
CHOLESTEROL___________________
BLEEDING DISORDER________________ BLOOD
CLOTS_________________________
ASTHMA, EMPHYSEMA_______________
ALZHEIMERS__________________________
DEPRESSION________________________
SCHIZOPHRENIA_______________________
ALCOHOL/DRUG_____________________ GALLBLADDER________________________
LIVER DISEASE______________________
ULCERS_______________________________
KIDNEY TROUBLE___________________
THYROID______________________________
ARTHRITIS TYPE?__________________
AUTOIMMUNE_________________________
OSTEOPOROSIS_____________________ EARLY MENOPAUSE___________________
CATARACTS________________________ GLAUCOMA___________________________
HEARING LOSS_____________________ MENTAL RETARDATION________________
OTHER GENETIC
DISORDER__________________________________________________________
FOR WOMEN ONLY: AGE OF FIRST MENSTRUAL PERIOD____________
AGE AT MENOPAUSE ___________
PERIODS WERE GENERALLY REGULAR___IRREGULAR____
IF YOU STILL GET PERIODS:
PADS/TAMPONS PER DAY_______ DAYS IT LASTS________
DAYS BETWEEN START OF ONE START OF NEXT_______
NUMBER OF PREGNANCIES____ LIVE BIRTHS__________
TERM ____ PREMATURE____ PREG LOSS/ABORTION____
ANY OVER 10 POUNDS?_____PREGNANCY COMPLICATIONS DIABETES,
BLOOD
PRESSURE?___________________________
REVIEW OF SYSTEMS
CIRCLE IF YOU FREQUENTLY OR RECENTLY HAVE HAD:
WEIGHT CHANGE APPETITE CHANGE FATIGUE FEVER
SKIN RASH BRUISES BLEEDING HEADACHE VISION CHANGE
HEARING CHANGE VERTIGO COLDS ALLERGIES NOSEBLEEDS
SINUS INFECTION SORE THROAT HOARSENESS
CHEST PAIN PALPITATIONS SHORTNESS OF BREATH
WHEEZING CHRONIC COUGH HEARTBURN NAUSEA
CONSTIPATION DIARRHEA BLOOD IN STOOL
ABDOMINAL OR PELVIC PAIN RECTAL BLEEDING/PAIN
PAINFUL URINATION DECREASED URINE STREAM/DRIBBLING
URINATION AT NIGHT FREQUENT URINATION BLOOD IN URINE
HEAVY PERIODS SKIPPED PERIODS VAGINAL DISCHARGE TESTICULAR
PAIN/SWELLING MUSCLE ACHES NIGHT SWEATS
JOINT PAIN/SWELLING FEEL COLD FEEL HOT HAIR LOSS
DECREASED SEXUAL DESIRE ERECTION OR ORGASM DIFFICULTIES
ANXIETY CRYING SPELLS IRRITABILITY/ANGER
TROUBLE SLEEPING MEMORY PROBLEMS LOW MOTIVATION
TROUBLE CONCENTRATING FEELING WORTHLESS HIGH STRESS
OTHER
CONCERNS:_____________________________________________________
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Source:synspectrum.com
