Medication - Lofts Medical Associates

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LOFTS MEDICAL ASSOCIATES
HEALTH HISTORY
PATIENT INFORMATION
Patient Name: Last _______________________________ First _______________________________
Sex
M
F
Date of Birth ______/______/________
Your answers on this form will help your clinician understand your medical concerns and conditions better. If you are
uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember specific details.
Thank you!
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs:
Medication
Dose
Times per day
Medication
Dose
Times per day
ALLERGIES or REACTIONS TO MEDICINES/FOODS/OTHER AGENTS:
Medication
Reaction or Side Effect
PERSONAL MEDICAL HISTORY
Please indicate whether you have had any of the following medical problems (with approximate date of illness or diagnosis):
___ Congenital Heart disease:
specify type _____________
___ Myocardial Infarction (Heart
attack)
___ Hypertension (High blood pressure)
___ Diabetes
___ High cholesterol
___ Stroke
___ Coagulation (bleeding/clotting)
disorder
___ Cancer (Malignancy)
specify type _____________
___ Depression/suicide attempt
___ Alcoholism
___ Thyroid problem
specify type _____________
___ Other problems
___ When was your last Tetanus shot?
SURGICAL & HOSPITALIZATION HISTORY (Please list all prior operations and dates):
Operation
Date
SOCIAL HISTORY
Tobacco Use:
Cigarettes
___ Quit: Date__________
___ Never
___ Current: Smoker: packs/day____ # of yrs ________
Are you interested in quitting? ___ No ___ Yes
Hospitalization
Date
Caffeine Use
Do you drink liquids containing caffeine? ___ No ___ Yes
Alcohol Use
Do you drink alcohol? ___ No ___ Yes: # drinks/week_____
EXERCISE:
Do you exercise regularly? ___ No ___ Yes
FAMILY HISTORY
Please indicate with a check (√) family members who have had any of the following conditions:
Medical
Condition
Mom
Dad
Sist.
Bro.
GRParent
other
Anemia
Glaucoma
Medical
Condition
Mom
Dad
Sist.
Bro.
GR-Parent
other
Stroke
Breast
Cancer
Colon
Cancer
Ovary
Cancer
Prostate
Cancer
Lupus
Asthma
Heart
Attack
High Blood
Pressure
High
cholesterol
Kidney
diseases
Depression
Alcoholism
Thyroid
disorders
Epilepsy
Diabetes,
Type 1
Diabetes,
Type 2
Bleeding
problem
IMMUNIZATIONS
Please list your most recent immunizations. Please include your best estimate of the month and year of each immunization.
DATE IMMUNIZATION
Hepatitis A
Hepatitis B
Tetanus (Td)
Tetanus (Tdap)
DATE
IMMUNIZATION
Measles
Mumps
Rubella
MMR
DATE
IMMUNIZATION
Pneumovax (Pneumonia)
Varicella shot (Shingles)
Other:
REVIEW OF SYSTEMS
Please check (√) any current problems you have on the list below.
Constitutional
___Fevers/chills/sweats
___Fatigue/weakness
___Excessive thirst or urination
Eyes
___Change in vision
Ears/Nose/Throat/Mouth
___Difficult hearing/ringing in ears
___Problems with teeth/gums
___Hay fever/allergies
Cardiovascular
___Chest pain/discomfort
___Leg pain with exercise
___Palpitations
Skin
___ Rash or mole change
Gastrointestinal
___Abdominal pain
___Blood in bowel movement
___Nausea/vomiting/diarrhea
Psychiatric
___Anxiety/stress
___Problems with sleep
___Depression
Chest (breast)
___Breast lump/discharge
Respiratory
___Cough/wheeze
___Difficulty breathing
Musculo-skeletal
___Muscle/joint pain
Blood/Lymphatic
___Unexplained lumps
___Easy bruising/bleeding
Genitourinary
___Nighttime urination
___Leaking urine
___Unusual vaginal bleeding
___Discharge: penis or vagina
___Sexual function problems
Other (please specify)
____
Neurological
___Headaches
___Dizziness/light-headedness
___Numbness
___Memory loss
___Loss of coordination

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