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Comprehensive Patient History Form

This document contains a patient's current history review form collecting information such as contact details, reason for visit, medical history including hospitalizations and surgeries, current medications, allergies, lifestyle habits, gynecologic history, family medical history, review of symptoms in different body systems, and questions about topics the patient wants to discuss. The form collects comprehensive health information through checkboxes and short answers to help evaluate the patient's condition and needs.

Uploaded by

Thirumalai Vasan
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
59 views2 pages

Comprehensive Patient History Form

This document contains a patient's current history review form collecting information such as contact details, reason for visit, medical history including hospitalizations and surgeries, current medications, allergies, lifestyle habits, gynecologic history, family medical history, review of symptoms in different body systems, and questions about topics the patient wants to discuss. The form collects comprehensive health information through checkboxes and short answers to help evaluate the patient's condition and needs.

Uploaded by

Thirumalai Vasan
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Current History Review

Name Street Address City, State, Zip Occupation Home Phone Work Phone Insurance Spouse/Partners Name Date Birthday Marital Status Education

What brings you to the office today?

Annual Exam/Routine Care Problem/Issue (Please describe briefly) I was referred by


Past Hospitalizations and Surgery:

Current Medications:

Allergies to Medications:

Bad Habits Yes No Describe Smoking Alcohol Illegal Drugs

Gynecologic History Last Menstrual Period: Last Pap Smear: Last Mammogram: Current Method of Contraception: Every Days. Lasting Days. Normal? Normal?

Have you or anyone in your family suffered from: (Indicate relationship)

Diabetes Stroke
General Lungs

Heart Disease High Blood Pressure


Musculoskeletal

Drinking Problem Breast Cancer


Menstrual Problems

Ovarian Cancer Colon Cancer


Other Gynecologic Issues

Have you had problems with any of the following within the past year?

Weight Loss or
Gain

Fevers Trouble Sleeping Chronic Fatigue Excessive Bleeding Easy Bruising Abnormal Thirst
Eyes

Coughing Up Blood Shortness of Breath Chronic Cough Blood Clot in the Lungs Painful Breathing Wheezing
Cardiovascular

Muscle Weakness Joint Pains Joint Swelling Clot in Leg Vein


Neurologic

Itchy, Red Eyes Vision Problems


Ears

Chest Pain Irregular Heart Beat Ankle/Hand Swelling


Gastrointestinal

Frequent/Severe Headaches Dizziness Seizures Numbness Trouble Walking Fainting Spells


Skin

Cramps/Pain Heavy Bleeding Too Frequent Periods Bleeding Between Periods Missed a Period Other Period Issue
Pre Menstrual Problems

Vaginal Discharge Itching/Irritation Vulvar Pain Vulvar lump/growth Vulvar Sores


Sexual Problems

Ear Pain Ringing in Ears Hearing Loss


Nose

Sinus Problems Nose Bleeds


Mouth

Frequent Diarrhea Constipation Bloody Stools Nausea/Vomiting Hemorrhoids


Urinary

Acne Unwanted Hair Growth Unusual Lump or Growth Dry Skin


Emotional

Bloating/Swelling Mood Changes Breast Changes Headaches Acne Other PMS Issue
Menopause Issues

Painful Intercourse Bleeding after Intercourse Decreased Desire Orgasm Problems Dryness Possible Exposure to STD Other Sexual Issue
Would you like to discuss any of the following?

Hot Flashes Night Sweats


Breast Problems

Sore Throat

Incomplete Urination Loss of Urine

Excessive Worry Depression

Breast Pain Breast Lump

Contraception Menopause Issues Pregnancy Issues Self Breast Exam Sexuality Issues

Current History Review


Mouth Sores Dental Problems
Signature:

Painful Urination Bloody Urine

Frequent Crying Serious thoughts of harming

Nipple Discharge Other Breast Issue

STDs Other

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