Patient Medical History Questionaire

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MikeBartolatz Registered User (9/29/03 12:20 pm)	Patient Medical History Questionaire -------------------------------------------------------------------------------- The document below is used at MEEI to give the specialists pertinent information for review of patient medical history. I suggest that all print it out and fill it in prior to going to any specialist. mike This is a confidential survey. Please repond to all questions. Patient Name:_________________________________________________________ Address: _____________________________________________________________ Telephone Number: _________________________________ Referring Physician: ___________________________________________________ Address: _____________________________________________________________ Telephone Number: _________________________________ FAMILY HISTORY: These questions refer to your grandparents, parents, aunts, uncles, brothers and sisters, children or grandchildren. Has anyone in your family had any of the following? PLEASE ANSWER YES or NO. Cancer Diabetes Allergies Arthritis or rheumatism Syphilis Tuberculosis Sickle cell disease or trait Lyme disease Gout Has anyone in your family had medical problems listed below? PLEASE ANSWER YES or NO. Eyes Skin Kidneys Lungs Stomach or bowel Nervous system or brain SOCIAL HISTORY: Age (Years): ________________ Current job: _______________________________ Have you lived outside the U.S.A.? If yes, where? _______________________________________ Have you ever owned a dog? Have you every owned a cat? Have you ever eaten raw meat or uncooked sausage? Have you ever had unpasteurized milk or cheese? Have you ever been exposed to sick animals? Do you drink untreated stream, well or lake water? Do you smoke cigarettes? Have you ever used intravenous drugs? Have you ever had a bisexual or homosexual relationships? Have you ever taken birth control pills? PERSONAL MEDICAL HISTORY: Are you allergic to any medications? If yes, which medications? _______________________________________________ Please list the medications that you are currently taking, including non-prescription drugs such as aspirin, Advil, antihistamines, etc. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ PAST MEDICAL HISTORY: Please list all eye operations you have had (including laser surgery), and the dates of the surgeries. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please list all other operations that you have had and the dates of the surgeries. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you ever been told that you have the following conditions? PLEASE ANSWER YES or NO. Anemia (Low Blood Counts) Cancer Diabetes Hepatitis High Blood Pressure Pleurisy Pneumonia Ulcers Herpes (cold sores) Chicken Pox Shingles (Zoster) German Measles (Rubella) Measles (Rubeola) Mumps Chlamydia or Trachoma Syphilis Gonorrhea Any other sexually transmitted disease Tuberculosis (TB) Leprosy Leptospirosis Lyme Disease Histoplasmosis Candida or Moniliasis Coccidiomycosis Sporotrichosis Toxoplasmosis Toxocariasis Cysticercosis Trichinosis Whipple’s Disease AIDS Hay Fever Allergies Vasculitis Arthritis Rheumatoid Arthritis Lupus (Systemic Lupus Erythematosus) Scleroderma Have you ever had any of the following illnesses? PLEASE ANSWER YES or NO. Reiter’s Syndrome Colitis Crohn’s Disease Ulcerative Colitis Behcet’s Disease Sarcoidosis Ankylosing spondylitis Erythema Nodosa Temporal Arteritis Multiple Sclerosis Serpiginous Choroidopathy Fuchs’ Heterochoromic Ididocyclitis Vogt-Koyanagi-Harada Syndrome Have you had any of the following symptoms in the past year? PLEASE ANSWER YES or NO. GENERAL HEALTH: Chills Fevers (persistent or recurrent) Night Sweats Fatigue (tire easily) Poor Appetite Unexplained Weight Loss Do you Feel Sick HEAD: Frequent or Severe Headaches Fainting Numbness or Tingling in your body Paralysis in parts of your body Seizures or Convulsions EARS: Hard of Hearing or Deafness Ringing or Noises in Your Ears Frequent or Severe Ear Infections Painful or swollen Ear Lobes NOSE AND THROAT: Sores in Your Nose or Mouth Severe or Recurrent Nosebleeds Frequent Sneezing Sinus Trouble Persistent Hoaresness Tooth or Gum Infections SKIN: Rashes Skin Sores Sunburn Easily (Photosensitivity) White Patches of Skin or Hair Loss of Hair Tick or Insect Bites Painfully Cold Fingers Severe Itching RESPIRATORY: Severe or Frequent Colds Constant Coughing Coughing Up Blood Recent Flu or Viral Infection Wheezing or Asthma Attacks Difficulty Breathing Have you ever had any one of the following symptoms? PLEASE ANSWER YES or NO. CARDIOVASCULAR: Chest Pain Shortness of breath Swelling of your legs BLOOD: Frequent or Easy Bruising Frequent or East Bleeding Have you Received Blood Transfusions GASTROINTESTINAL: Trouble Swallowing Diarrhea Bloody Stools Stomach Ulcers Jaundice or Yellow Skin BONES AND JOINTS: Stiff Joints Painful or Swollen Joints Stiff Lower Back Back Pain while Sleeping or Awakening Muscle Aches GENITOURINARY: Kidney Problems Bladder Trouble Blood in your Urine Urinary Discharge Genital Sores or Ulcers Prostatitis Testicular Pain Are you Pregnant? Do you Plan to be Pregnant in the Future? -------------------------------------------------------------------------------- Next Topic >>

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