Patient History Patient History Patient InformationLast Name*First Name*MIDOB* SS#*Phone*In Case of Emergency, Please Notify*Patient Medical HistorySelect any diseases/ symptoms that you currently have or have been previously diagnosed. Strokes Heart Attack High BP Dizziness Irregular Pulse Murmur Rheumatic Fever Hay Fever Sleep Disorder Swollen Lymph Nose Bleeding Dentures/Partials Blindness Glaucoma Glasses Slipped Disk Scoliosis Arthritis/Gout Fibromyalgia Epilepsy Migraine Headache Jaundice Anemia Diabetes Heart Failure Heart Disease Chest Pain Swollen Ankles Short of Breath High Cholesterol MVP (Mitral) Deafness Thyroid Disease Hoarseness Sore Throat Root Canal/Gums Blurred Vision Itchy Eyes Contact Lenses Back Pain Brittle Bones Joint Disease Muscle Tremors Headache Paralysis Liver Disease Leukemia Hepatitis Depression Alcoholism Bulimia/Anorexia Anxiety Asthma Smoking Tuberculosis Chemical Exposure Sores Acne Skin Diseases Ulcers Colitis Diarrhea Hiatal Hernia Polyps Diverticular Abdominal Pain Nausea Weight Gain/Loss Kidney Failure Kidney Stones Venereal Disease Suicide Attempt Drug Use Mental Illness Insomnia Emphysema Pneumonia Asbestosis Bronchitis Mole Change Radiation Expose Eczema/Psoriasis Gall Stones Blood in Stool Vomiting Reflux Change in Bowels Hemorrhoids Indigestion Constipation Cancer HIV Exposure Previous Hospitalizations And SurgeriesDateSurgery Performed or Illness TreatedHospital or Physician Current Medications ( Prescription, Vitamins, Herbs, Etc. )Description Immunization HistoryHepatitis BNoYesWhen TetanusNoYesWhen InfluenzaNoYesWhen TB TestNoYesWhen PneumovaxNoYesWhen OtherWhen Date Physician NotesI have reviewed the above information with the patient on the date indicated below.Date* Current Problem ListFemales OnlyAge at onset of PeriodsFrequencyDurationPregnanciesBirthsMiscarriages Prolonged Bleeding Abnormal Pap Smear Lump in Breast Endometriosis Pelvic Pain/Tenderness Leakage or Blood in Urine Breast Cancer Abnormal Discharge Difficulty Urinating Mastectomy Date of Your Last Menstrual Period Date of Your Last Pap Smear Date of Your Last Breast Exam Date of Your Last Mammogram Males Only Foreskin Irritation Urethral Discharge Vasectomy Prostate Problems Difficulty Starting Urination Difficulty With Erection Leakage or Blood in Urine Date of Your Last Prostate Exam: Family HistoryHas any member of your family (including parents, grandparents and siblings) ever had:Illness Which family member Age at OnsetCancer (describe)Which family MemberAge of OnsetHypertension (High BP)Which family MemberAge of OnsetHeart DiseaseWhich family MemberAge of OnsetDiabetesWhich family MemberAge of OnsetStrokeWhich family MemberAge of OnsetMental DiseaseWhich family MemberAge of OnsetDrug/Alcohol ProblemWhich family MemberAge of OnsetGlaucomaWhich family MemberAge of OnsetBleeding DiseasesWhich family MemberAge of OnsetOtherWhich Family MemberAge of OnsetKnown AllergiesDrug/Food/InsectsReaction This iframe contains the logic required to handle Ajax powered Gravity Forms.
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