Patient Medical History

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2 Cardiovascular Abnormal Electrocardiogram Aortic Stenosis Atrial fibrillation Cardiac arrest Chest pain Congestive heart failure Heart valve replacement Hypertension Murmur Heart attack Palpitations Peripheral vascular disease Pulmonary embolism Faint Ventricular septal defect Respiratory Asthma Bronchitis, chronic Cough Emphysema Lung Cancer Pneumonia Shortness of breath Sinusitis, chronic Digestive Appendicitis Blood in stool Colon cancer Constipation Diarrhea Diverticula of intestine Esophageal reflux Heartburn Hemorrhoids Hepatitis Hernia Incontinence of feces Intestinal obstruction Irritable bowel syndrome Liver disorder Nausea Nausea with vomiting Peptic ulcer Rectal bleeding Vomiting Endocrine/Metabolic/Immune Type I Diabetes insulin use Type II Diabetes non insulin High cholesterol High thyroid Low thyroid Pituitary gland disorder Patient Medical History Vitamin deficiency Weight gain, abnormal Weight loss Neurologic Alzheimer s disease Convulsions CVA cerebrovascular accident Gait abnormality Headache Hemipelgia Lack of coordination Meningitis Migraine Multiple Sclerosis Neuropathy Numbness Parkinson s Disease Post stroke paralysis Speech disturbance Renal/GU Bladder disorder Kidney stone Painful urination ESRD End stage renal disease Family history of Prostate cancer Blood in urine Impotence cause undetermined Prostate cancer Prostatic hypertrophy benign Urinary incontinence Hematologic Anemia Leukemia Transfusion reaction Musculoskeletal Arthritis rheumatoid Backache Bone infection Bunion Bursitis Connective tissue disease Ganglion Joint pain Muscle spasm Osteoporosis Rotator cuff syndrome of shoulder Sciatica Breast Abnormal mammogram Breast mass Nipple discharge Name: Skin Basal cell carcinoma Cellulitis and abscess Contact dermatitis Edema Malignant melanoma Skin disorder Psychiatry Alcohol withdrawal Anxiety disorder Bipolar disorder Insomnia Major depression recurrent Major depression single episode Mental retardation Panic disorder Schizophrenia Gynecologic Abnormal PAP smear Cervical cancer Hormone replacement therapy Menopausal syndrome Pelvic pain Polycystic ovaries Obstetric Diabetes gestational Infertility Spontaneous abortion Tubal pregnancy Injury/Poisoning Concussion Fracture Head injury Head injury, closed Motor Vehicle Accident Nerve injury Have you ever had a blood transfusion? Yes No If yes approx. dates: Tobacco Alcohol Illegal Drugs Never Current Former

3 Family Medical History Please check all that apply. Use the line provided to add details of the family member and his/her current health. Please include maternal or paternal where appropriate. Cardiovascular Abdominal aneurysm CVA Family history non contributory Heart disease Hyperlipidemia Hypertension Sudden death Syncope faint Transient Ischemic Attack TIA Endocrine Diabetes Type I Diabetes Type II Hyperthyroidism Hypothyroidism Morbid obesity Neurologic Alzheimer s disease Chorea Common migraine Convulsions Gait abnormality Hearing loss Huntington s disease Involuntary movement disorder Meningitis Motor neuron disease Multiple Sclerosis Neuropathy Parkinson s disease Spinal cord disease Stroke Respiratory Asthma Chronic bronchitis Emphysema Lung disease Lung cancer Sleep apnea Hematologic Anemia Psychiatric Anxiety disorder Bipolar disorder Dementia conditions Depression Psychiatric disorder Gastrointestinal Anus cancer Colon cancer Intestinal obstruction Liver disorder Breast Breast cancer Breast cyst Cancer Cancer Musculoskeletal Arthritis, rheumatoid Joint disorder Muscle disorder Muscular dystrophy TIA Hospitalizations/Surgeries Year Hospital Reason for your Hospitalization/Surgery

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7 JEFFREY D. RIES, D.O SAN BERNARDINO ROAD, # 101 UPLAND, CA (909) FWY N SAN ANTONIO HOSPITAL FOOTHILL BLVD E. ARROW HWY 10 FWY 60 FWY IMPORTANT INFORMATION PLEASE READ **Our suite is located through the glass door on the left end of the building (Note: bathrooms are located in the hall of the main building. There is no bathroom located in the office.) **Please bring a list of your current medications to your appointment **Please bring the films or CDs from any recent studies to your appointment. (If your studies were done at San Antonio Hospital, disregard this) **ALL PATIENTS ARE SUBJECT TO A 24 HOUR CANCELLATION FEE! SEE FINANCIAL POLICY FORM FOR MORE DETAILS. **Para nuestros pacientes que hablan solamente español, les agradeceriamos si pudieran traer un intreprete que hable ingles.

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