Name

Date

Age

DOB

Sex

Height

Weight

WHAT IS THE MAIN REASON FOR YOUR VISIT TODAY (required)

Any weight changes?

Yes

No

How many pounds

Loss

Gain

Fever/Chills?

Yes

No

Past medical history

Chest pain / Tightness

Heart problems

Shortness of breath

Swelling feet/Legs

Blood clots

Diabetes

Heart palpitations

Atrial fibrillation

Night sweats

Emphysema/COPD

Asthma

Bronchitis

Epilepsy

Sleep apnea/snoring

Stroke

Weakness

Thyroid Issues

Convulsions

Migraines

Passing out

Depression/anxiety

Hallucinations

Speech issue

Swollen glands

Lumps in neck

Rash

Prostate issue

Menstrual issue

Cervical neck issue

Canser

Liver disease

High blood pressure

Tuberculosis

HIV

Mental illness

Lyme disease

Mononucleosis

Social history

Occupation

Smoker

If yes how much

Prior tobacco use

For how long?

Quit

Alcohol

If yes how much?

Heavy drinker

Any drug use

Caffeine/soda/tea

If yes how much

Past Surgical History

Tonsillectomy

Adenoidectomy

Nose/Sinus

Ear/mastoid

Tubes

Appendix

Gallbladder

Hernia

Breast canser

Breast biopsy

Prostate

Hysterectomy

Skin canser

Colon canser

Recent Colonoscopy/esophagoscopy

Lung

Thyroid

Salivary Galen

Other

Current medications

Must be completed or attatched

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Medication Name

Strength

Frequency

Got a list of current medications?

DRUG ALLERGIES

FOODANIMAL ALLERGIES

FAMILY HISTORY

Check any condition that YOUR FAMILY may have.

Diabetes

High blood pressure

Heart disease

Dizziness

Cancer

Hearling loss

Otosclerosis

Allergies

Asthma/Emphysema

Sleep apnea

Mental illness

Neurologic issues

Tuberculosis

Alcohol/drug addiction

Thyroid disease

Kidney disease

Myasthenia gravis

Parkinsons disease

Sarcoidosis

Lupus

Eczema

Psoriasis

Brain tumor

Aneurysm

Have you had an X-ray, MRI, CT scan or blood work pertaining to your visit today?

E-Signature

Please sign electronically below.

HISTORY & PHYSICAL

Past medical history

Social history

Past Surgical History

Current medications

Got a list of current medications?

FAMILY HISTORY

E-Signature