|
Past Medical History
|
|
|
ENT Hx
• • •
|
Other
|
|
Eye Hx
• • •
|
Other
|
|
Cardiovascular Hx
• • •
|
Other
|
|
Circulatory System
• • •
|
Other
|
|
Genitourinary
• • •
|
Other
|
|
Neurologic
• • •
|
Other
|
|
Endocrine & Metabolic
• • •
|
Other
|
|
Hematology
• • •
|
Other
|
|
Psychiatry
• • •
|
Other
|
|
Drug Abuse
|
|
|
Gastrointestinal
• • •
|
Other
|
|
Pulmonology
• • •
|
Other
|
|
Musculoskeletal
• • •
|
Other
|
|
Skin
• • •
|
Other
|
|
Pets
|
Additional Info
|
|
Travel History
|
Origin
|
|
Infectious Diseases
|
|
|
History of STD
|
History of STD (Add Info)
|
|
History of MRSA
|
Other
|
|
Other Medical Problems
|
|
|
Other 1
|
Other 2
|
|
Other 3
|
Other 4
|
|
Social History
|
|
|
Highest Level of Education
|
Occupation
|
|
Military Service
|
Marital Status
|
|
Living Arrangements
|
Lives with (other)
|
|
Alcohol Consumption
|
|
|
Current Status
|
Sober Since
|
|
Type
• • •
|
Frequency
|
|
Drinks/day
/
|
Drinks/week
/
|
|
History of Tobacco Use
|
|
|
Status
|
Cigarettes, PPD
|
|
Date started
|
Date Quit
|
|
Fx Cigar Smoking
|
Fx Chew Tobacco
|
|
Recreational Drugs
|
Drugs/Details
|
|
Surgical History
|
|
|
Surgery
• • •
|
Date
|
|
1. Surgery
|
Date
|
|
2. Surgery
|
Date
|
|
3. Surgery
|
Date
|
|
Hospitalization History
|
|
|
1. Hospitalization
|
Date
|
|
2. Hospitalization
|
Date
|
|
3. Hospitalization
|
Date
|
|
4. Hospitalization
|
Date
|
|
5. Hospitalization
|
Date
|
|
Family History
|
|
|
Unknown reason
|
|
|
Father
• • •
|
Other history of Father
|
|
Mother
• • •
|
Other history of Mother
|
|
Brother
• • •
|
Other history of Brother
|
|
Sister
• • •
|
Other history of Sister
|
|
Other relative
• • •
|
Other history of relatives
|
|
Comments:
|
|
|
Womens Health History
|
|
|
Female Health History
• • •
|
Other
|
|
Menstrual History
|
|
|
Age of first period (years)
|
Frequency of period (days)
|
|
Duration of period (days)
|
Post Menopausal (years)
• • •
|
|
Pregnancy History
|
|
|
Total # of pregnancies
|
NSVD
|
|
C-Sections
|
Miscarriages
|
|
Abortions
|
|
|
Birth Control Method
• • •
|
Other Method
|
|
Month/Year
|
Infant Sex
• • •
|
|
Birth Weight
|
Wks Gest
|
|
Type of Delivery
• • •
|
Anesthesia
• • •
|
|
Comments/Complications
|
|
