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Please check YES or NO
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Constitutional
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Do you have current fever or chills
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Do you have recent unintentional weight loss?
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Do you have excessive Lethargy/Fatigue?
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Do you have generalized muscle weakness?
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Cardiovascular System
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Are you having recent chest pain?
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Do you have swelling of feet and legs?
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Do you have irregular heart beat?
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Have you had a heart attack?
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Do you get leg pain or cramps when walking less then 2 city blocks?
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Have you had a stroke(CVA)?
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Respiratory System
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Do you have shortness of breath?
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Do you have asthma ?
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Do you have recent cough/sputum production?
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Do you have Chronic Obstructive Pulmonary Disease.
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Gastrointestinal System
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Do you have peptic ulcer or gastritis?
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Do you have hepatitis or liver disease?
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Genitourinary System
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History of kidney disease or renal insufficiency ?
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Hematologic
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Do you have history of blood clot?
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Do you have bleeding disorder?
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Do you have anemia?
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Neurological
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Do you have history of seizure disorder?
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Do you get foot or leg numbness?
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Do you get Radiating pain from back to leg/foot?
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Do you get leg weakness?
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Musculoskeletal System
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History of osteoporosis ?
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Do you get joint swelling or pain ?
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Do you have a history of gout ?
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Do you have lower back pain?
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Do you have history of rheumatoid arthritis ?
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Integument
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Do you have history of skin cancer ?
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Change in moles or skin color ?
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PAST MEDICAL HISTORY
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Click on for all positive responses
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No medical Illnesses
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Diabetes
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High Blood Pressure
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Coronary Artery Disease (CAD)
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Renal insufficiency/ Kidney Dz.
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High Cholesterol
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Currently Pregnant
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Asthma
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Thyroid Problems
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COPD / Emphysema
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Hepatitis/ Liver Disease
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Congestive Heart failure (CHF)
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Atrial Fibrillation
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Cancer
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Stroke. (CVA)
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Rheumatoid Arthritis
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Seizure disorder/ Epilepsy
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Depression
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Osteoporosis
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Pacemaker
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Stomach Ulcer
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Gastritis
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Bipolar /Schizophrenia
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Drug abuse
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Additional Medical Problems
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FAMILY HISTORY
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Family History of Cancer
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Family History of Diabetes
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Family History of Coronary Artery Disease
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Family History of Bleeding Disorder
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Family history of mental illness
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No Family History of major medical illness
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SOCIAL HISTORY
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Married
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Divorced
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Single
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Children
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Live Alone
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Are you a smoker?
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Do you drink alcohol
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Do you use illicit drugs ?
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History of substance abuse
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PAST SURGICAL HISTORY
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No previous Surgeries
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Knee Surgery
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Cardiac Surgery
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Lower extremity Vascular Surgery
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Intestinal Surgery
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Gall Bladder Removal
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Back Surgery
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Hernia Repair
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Hysterectomy
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Hip surgery
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Weight loss surgery
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Below Knee Amputation
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Shoulder Surgery
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Ankle Surgery
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Partial foot/ toe amputation
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Foot surgery
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Other surgeries
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