Form #2

This is the medical history portion of the forms. Please fill this out to the best of your ability.

New Patient Medical History

Name*
First Last
Email*
Date
MM slash DD slash YYYY
Age
Heart Trouble
Coronary Artery Disease Heart Attack Heart Failure Heart Murmur Pacemaker Defibrillator Other (specify)

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Heart Rhythm
Arrhythmia Atrial Fibrillation

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
High Blood Pressure

Please list the year you were diagnosed with this illness, if applicable.
High Cholesterol

Please list the year you were diagnosed with this illness, if applicable.
Brain
Stroke TIA Dementia Seizure Disorder Migraine Headaches

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
GI Disease
GERD/Heartburn Stomach Ulcer Duodenal Ulcer Diverticulitis

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Diabetes
High Blood Sugar Taking Insulin Not Taking Insulin

In each field, please list the year you were diagnosed with each illness. For taking insulin, simply answer Yes to one of the questions.
Thyroid
Low Thyroid High Thyroid

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Liver Disease
Hepatitis A Hepatitis B Cirrhosis Other

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Kidney
Chronic Kidney Disease Hemodialisys Peritoneal Dialysis Stones

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Lung Disease
Emphysema COPD Chronic Bronchitis Use Oxygen at ____lpm Asthma

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank. Please type the oxygen usage in the appropriate field if applicable.
Sleep Apnea
Using PAP Machine Using Mouthpiece Diagnosed but untreated

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Blood Disorders
Anemia Leukemia Bleeding Disorder (Specify Type) Other

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Eye Disease
Glaucoma Other (Specify Type)

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Arthritis
Degenerative Rheumatoid Gout Other

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Cancer

Please use the field to list the type and year of any Cancer diagnoses.
Psychological
Depression Anxiety Bipolar PTSD Schizophrenia Other

In each field, please list the year you were diagnosed with each illness. If they do not apply, please leave them blank.
Chronic Pain
Cervical/Neck Lumbar/Low Back
Other major illness:
Please use this field to list any other major illnesses. List the year diagnosed as well.

SURGERIES

Tonsillectomy	Nasal Septum	UPPP (Palate Surgery for Sleep Apnea)	Thyroid Removed	Thyroid: RAI Ablation	Hysterectomy	Coronary Artery Stents	Coronary Artery Bypass Surgery	Heart Valve Surgey	Artery Bypass Surgery / Stents in Legs	Gallbladder	Appendectomy	Prostate	Vasectomy	Hernia	Cervical (Neck)	Lumbar (Low Back)	Bariatric (Weight Loss)

Please enter the year of surgery for any of the applicable fields. If you did not have any of these surgeries, please leave them blank.

Other Surgeries

Please list any other surgeries and the year of the surgeries.
Major Injuries
Please any major injuries (auto accidents or trauma) you have experienced. Please also list the years for each injury.
Hospitalizations:
Please list any recent hospitalizations. (Last three months.)
Constitutional
- Recent weight change
- Fever
- Headaches
Please choose any symptoms you currently have.
Eyes
- Eye Disease
- Wear contacts/glasses
- Blurred Vision
Please choose any symptoms you currently have.
Respiratory
- Chronic coughs
- Shortness of breath
- Wheezing
Please choose any symptoms you currently have.
Genitourinary
- Frequent urination
- Blood in urine
- Impotence
Please choose any symptoms you currently have.
Ear/Nose/Throat/Mouth
- Hearing loss
- Earache
- Nose bleeds
Please choose any symptoms you currently have.
Cardiovascular
- Chest pain
- Palpitations
- Swelling in extremities
Please choose any symptoms you currently have.
Musculoskeletal
- Joint pain
- Weakness of muscles
- Back pain
Please choose any symptoms you currently have.
Gastrointestinal
- Loss of appetite
- Nausea / Vomiting
- Abdominal pain
Please choose any symptoms you currently have.
Endocrine
- Hormone problems
- Excessive thirst
- Skin becoming dryer
Please choose any symptoms you currently have.
Neurological
- Frequent headaches
- Dizziness
- Numbness
Please choose any symptoms you currently have.
Psychiatric
- Memory loss
- Nervousness
- Depression
Please choose any symptoms you currently have.
Integumentary
- Rash / itching
- Change in hair / nails
- Breast pain / lump
Please choose any symptoms you currently have.
Hematologic / Lymphatic
- Slow to heal after cuts
- Anemia
- Enlarged glands
Please choose any symptoms you currently have.
FAMILY MEDICAL HISTORY
MOTHER
Alive & Well Alive but suffers with: Deceased / Cause: Age of Death
FATHER
Alive & Well Alive but suffers with: Deceased / Cause: Age of Death
Health condition of extended family:
Stroke High Blood Pressure Heart Attack Congestive Heart Failure Diabetes High Cholestrerol Cancer: Type

Please list any extended family members that may suffer from these conditions. (siblings, children, grandparents)
SOCIAL HISTORY
Marital Status
- Married
- Separated
- Divorced
- Widow-Widower
- Single
Work Status:
- Working
- Retired
- Disabled
- Commercial Driver
I drink alcohol:
- None
- Occasionally
- Frequently
- Daily
- Weekends Only
Description
Describe generally the type of drink (beer, wine, liquor) and how much you consume when you drink.
I smoke:
- None
- Cigarettes
- Pipe
- Cigars
Smoker for how long?
- About 1 year
- Several Years
- Many Years
- Most of my adult life
Currently Smoke
How many packs per day. Recently quit smoking. If so, how long ago?
Chew tobacco
Yes No If yes, how many years?
MEDICATIONS
Please list all medications you are currently taking. (Names & Dosages)
Allergies
Penicillin Sulfa Keflex Codeine

Please use the space below to list your reactions if allergic to these drugs.
Other drug allergies
Use this space to list any other drugs you are allergic to, also list the reaction you experience.
Consent
I agree to the privacy policy.

Coronary Artery Disease	Heart Attack	Heart Failure	Heart Murmur	Pacemaker	Defibrillator	Other (specify)

Alive & Well	Alive but suffers with:	Deceased / Cause:	Age of Death

Stroke	High Blood Pressure	Heart Attack	Congestive Heart Failure	Diabetes	High Cholestrerol	Cancer: Type

How many packs per day.	Recently quit smoking.	If so, how long ago?

Arrhythmia	Atrial Fibrillation

Stroke	TIA	Dementia	Seizure Disorder	Migraine Headaches

GERD/Heartburn	Stomach Ulcer	Duodenal Ulcer	Diverticulitis

High Blood Sugar	Taking Insulin	Not Taking Insulin