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Medical History
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Visual Problems
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Comments
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Glasses
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Comments
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Cataracts
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Comments
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Double Vision
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Comments
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Glaucoma
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Comments
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Other
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Comments
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Nose Bleeds
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Comments
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Hay Fever
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Comments
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Sinus Infection
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Comments
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Other
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Comments
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Hearing Loss
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Comments
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Ringing in Ears
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Comments
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Pain in Ears
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Comments
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Drainage
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Comments
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Other
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Comments
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Frequent or Recent Sore Throat
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New Field
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Hoarseness
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New Field
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Other
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New Field
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Cough
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New Field
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Sputum or Phlegm
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New Field
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Asthma
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New Field
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Pneumonia
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New Field
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TB (Tuberculosis)
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New Field
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Coughing Up Blood
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New Field
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Irregular Heart or Pounding
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New Field
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Chest Pain
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New Field
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High Blood Pressure
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New Field
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Swelling in Feet or Hands
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New Field
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Shortness of Breath WITH Activit
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New Field
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Shortness of Breath Lying Flat
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New Field
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Phlebitis (Blood Clots in Legs)
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New Field
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Leg or Hip Pain with Walking
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New Field
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Nausea
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New Field
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Vomiting
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New Field
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Diarrhea
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New Field
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Constipation
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New Field
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Abdominal Pain
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New Field
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Ulcer
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New Field
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Vomiting Blood
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New Field
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Black Bowel Movements
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New Field
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Fresh Blood from Rectum
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New Field
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Gallbladder Problems
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New Field
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Yellow Jaundice
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New Field
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Hepatitis
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New Field
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Other
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New Field
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Need to Urinate During Night
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How Many Times?
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Difficulty Getting Urine Started
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New Field
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Bladder or Kidney Infections
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New Field
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Burning on Urination
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New Field
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Kidney Stones
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New Field
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Blood in Urine
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New Field
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Sexually Transmitted Diseases
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New Field
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Women Only-Menstrual Problems
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New Field
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Women Only-Pregnancies
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Number Live-Number Miscarriages
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Other
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New Field
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Dizziness
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New Field
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Paralysis
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New Field
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Seizures
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New Field
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Tremor
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New Field
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Other
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New Field
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Joint Pain
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New Field
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Swelling or Redness of Joints
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New Field
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Other
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New Field
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Diabetes
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Type I or Type II
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Thyroid Disease
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New Field
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Anemia
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New Field
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Bleeding Tendency
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New Field
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Chills, Fever, Night Sweats
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New Field
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Skin Disorder
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New Field
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Dental Problems or Recent Work
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New Field
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Other
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New Field
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New Field
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New Field
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New Field
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New Field
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New Field
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New Field
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New Field
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New Field
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New Field
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New Field
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New Field
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Cholecystectomy
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New Field
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Adenoidectomy
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New Field
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CABG
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New Field
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Heart stent
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New Field
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Breast Biopsy
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Past surgical history
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Partial Mastectomy
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Appendectomy
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Full Mastectomy
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Angioplasty
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Above the knee amputation
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Tonsillectomy
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Back/Neck
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Heart valve repair
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Vasectomy
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Thyroidectomy
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Other
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Intestinal Surgery
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Illnesses
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Weight Loss Surgery
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Chicken Pox
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Below the knee amputation
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Measles
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Joint replacement
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Pneumonia
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Hysterectomy
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Scarlet Fever
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Other-Please list
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Rheumatic Fever
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Family History
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Whooping Cough
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Other
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Father's MH
• • •
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Comments
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Mother's MH
• • •
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Sibling(s)' MH
• • •
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Grandparent's MH
• • •
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Children(s)' MH
• • •
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Comments
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Social History
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Comments
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Marital Status
• • •
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Comments
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Living Arrangements
• • •
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Occupation
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Potential Environmental Pathogen
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Caffeine
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Comments
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Alcohol
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Other substances
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Patient's diet
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