Nome: Dote:

Birthdote: Age: Dote of lost physicol exominotion:

Occupotion:

Reoson for visit todoy:

MEDICATIONS List ollmedicotions you ore currently toking

i/tEDlCA[ HISTORY Check ( /l the medicol conditions you hove or hove hod in the post.I AIDSE Alcoholismn Anemiofl AnorexioE Appendicitisn Arhritisfl AsthmoD Bleeding Disorders[J Breost LumpE Bronchitisfl BulimiofJ ConcerD Cotorocts

[J ChemicolDependencyE Chicken PoxE Diobetesfl EmphysemoD EpilepsyE GollBlodder Diseosefl GloucomoE Goiter[] GonorrheoE Goutn Heort DiseoseE Hepotitis[] Hernio

o

lJ HerpesE High CholesterolE HIV Posilive[3 Kidney DiseoseD liver Diseosefl MeoslesE Migroine Heodoches[l Miscorriogefl lvlononucleosisI Muhiple SclerosisD Mumpsfl Pocemokerfl Pneumonio

E Polion Proslote Problemfl Psychiotric Corefl Rheumotic FeverI Scorlet FeverE StrokeD Suicide Atiempt[J Thyroid ProblemsE Tonsillitis[] TuberculosisD Typhoid Fevern UkersE VoginollnfectionsD VenereolDiseose

SYMPTOII S Check ( ,/ ) symptoms you currently hove or hore hod in the post yeor.GENERAT

X Chills[J Depressionfl Dizzinessn Fointingf] FeverI ForgetfulnessE HeodocheE Loss o[ sleepn Loss o[ *eight[--] Nervousnessn Numbness[-: Sweots

MUSCTEIJOTNT/BONEPoin, weokness, numbness in:

GASTROINTESTINAT

E Appetite poor[I Blooting[l Bowel chongesn ConstipotionD Diorrheof] Excessive hungerfl Excessive thirstn Gosn HemorrhoidsI lndigestionI NouseoE RectolbleedingE Stomoch poinn Vomitingfl Vomiting blood

CARDIOVASCULAR

[J Lhest pornu High blood pressureI lrregulor heort beoiE Low blood pressuren Poor circulotion[I Ropid heort beotn Swelling of onklesfI Voricose veins

EYE, EAR, NOSE, THROAT

E Bleeding gumsE Blurred visionfl Crossed eyesE Difficulty swollowingE Double visionLl Eorochen Eor dischorgen Hoy levern Hoorsenessn Loss of heoringI NosebleedsE Persistent coughE Ringing in eorsfl Sinus problemsfl Vision - FloshesE Vision - Holos

SKINI Bruise eosilyE Hivesn ltchingtl Chonge in molesn Roshn Scors[] Sores thot won't heol

MEN only[J Breost lumpE Erection difficultiesD Lump in testicles[l Penis dischorgefl Sore on penisn Other

WOMEN only[] AbnormolPop SmeorI Bleeding beh,veen periodsI Breost lumpE Extreme menstruol poinn Hotfloshesrl Nipple dischorgeD Poinful lntercourse[J Voginoldischorgen otherDote of lostmenstruol period

Dote o[ lostPop Smeor

Hove you hod ^o mommogromg

Are you pregnont?

Number of children

[] ArmsE BockI Feet[] Honds

[J Hipsn LegsU NeckE Shoulders

GENITO.URINARY

I Blood in urineE Frequent urinstionD Lock of blodder controlE Poinfulurinotion

Reoron lor lbsrftslhaion ond Oukornc

flvo I ruoHove vou ever hod o blood trsnsfusion?lf yes] pbose give opproximote dotes:-

OCCUFA?IONAL CONCERNSCheck.( { | il y*, *ork orposes youlo the iotlowrng:

HEALTH HABlfg Check l/ )"'hichrubsficnces you ule ond indicote

PNEGNANCY HISTORY

'g;x t# Complicotions if onyha, rnuch you use

I Hozordous Substrcnces_ Heovy Uftng

I E Alcohol

ifAfttLY HISTORY Fill in heohh inftrmotion obout your fomily.I State of tAoc ot

, Agc i l{celrh lfrofi

I ceaifo rhcf tu oborrc inhrrrotion is coerccf to *rc bcrt of my knovrl.dgc. I will not hold ,y &cor or ony rncnrbcr of hi/har rtJfcrporriblc h" *y cnEn or omnrisionr thot I mry horc rneds in fr eomphtion o[ thlr brm.

Signolurs

Cloll! / l if your blood rclotiws hod ory of thc hllowing

, Revicncd By DotE,'!4rilCf(F6 tAt t-8q!.Zl-..6d1

Sacks medical pack_finalpage 3 medical history