Name
Date
Age
+-
Specific reason for visit today (max 2)
Date of Last Physical Examination
Date of Last Menstrual Cycle
Current medications (include dosage and direction)
Tobacco usage
YesNo
If yes, how much?
Employment
Alcohol usage
If yes, # of drinks weekly?
Highest level of education
*Please check all that applies either to you or your family and give specific details.
Accident
PatientFamilyN/A
Details/Type
Kidney Disease
ADHD
Learning Disability
Arthritis
Liver Disease
Asthma
Lung Disease
Blood Disorder
Mental Illness
Cancer
Migraine
Dementia
Neurological Disease
Depression
Seizure
Diabetes
Sinusitis
Eye Disorder
Skin Disease
Glasses/contacts
Spine Disease
Head Trauma
Stomach Disease
Hearing Disorder
Stroke
Heart Disease
Thyroid Disease
High Cholesterol
Surgery
Hypertension
Other medical/illness history
Appetite Loss
Chills
Dietary Changes
Fatigue
Fever
Lethargy
Night Sweats
Weight change
gainedlossN/A
Lbs
Neck Pain
Neck Stiffness
Swollen Glands
Loss of Consciousness
Numbness
Seizures
Spinning Sensation
Tremor
Visual Changes
Weakness
Tingling
Chest Pain
Fainting
Leg Cramps
Palpitations
Rapid Heart Rate
Shortness of Breath
Swelling of Extremities
Bruising
Excessive Sweating
Hair Loss
Hives
Itching
New Lesions
Rash
