HEALTH AND HISTORY FORM
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- Edwin Tate
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1 HEALTH AND HISTORY FORM Thank you for filling out this form. The information you provide will facilitate your visit and will be entered into your medical record. Please use either a black or blue ball point pen to fill out the form. MCN Provider: Your Name: Date of birth: Age: Height: Weight: Date of visit: Handedness (with which hand do you write, or throw a ball, for e.g.): Right / Left / Either Name of the doctor who referred you to our clinic: Briefly list the reason(s) for this visit: Medical History: Please indicate if you currently have, or have had in the past, any of the following: CONDITION YES (For our use) Anxiety Asthma Black Outs Blood Clots Cancer Depression Diabetes Emphysema Head Injury Please go to the next page... 1
2 Medical History: Please indicate if you currently have, or have had in the past, any of the following: (continued) CONDITION YES (For our use) Headaches Heart Disease High Blood Pressure High Cholesterol Kidney Disease Liver Disease Memory Problems Seizures or epilepsy Sleeping Problems Stroke Thyroid Disease Vehicular Accident Work-related Injury Any other condition(s) not listed above: Past Surgical History: Please list any surgeries you have had: SURGERY APPROXIMATE DATE Allergies: Please list any allergies or reactions you have had to drugs: Please go to the next page... 2
3 Personal History: Yes. How many packs a day? How many years have you smoked? Do you smoke? No. Have you ever smoked? Y / N. If "Yes", when did you quit? Do you drink alcohol? Y / N Approximate daily or weekly amount: Daily caffeine consumption (cups of coffee or cola, for e.g.)? Have you ever been on disability? Y / N Do you use street drugs? Y / N Have you ever been treated for chemical dependency? Y / N Marital Status: Married Single Divorced Widowed/Widower Domestic Partner If you have children, how many?_ Occupation: Education: Please list highest school grade attended Please go to the next page... 3
4 FAMILY HISTORY Yes. Age? Present state of health: Father: Alive? No. Age at death? Cause of death: Yes. Age? Present state of health: Mother: Alive? No. Age at death? Cause of death: Yes. Age? Present state of health: Spouse: Alive? No. Age at death? Cause of death: Brother(s) Y / N Sister(s) Y / N Circle all of the following illnesses that have occurred in your blood relatives (Parents, Grandparents, Siblings): Cancer: type: High blood pressure Diabetes High cholesterol Heart disease Stroke Migraines Seizures Tremor MS Parkinson's disease Osteoporosis Kidney disease Liver disease Asthma Colon problems Bleeding disorders Any other neurological disease Please go to the next page... 4
5 YOUR CURRENT MEDICATION LIST: Name of prescription or over-thecounter medication Strength (How many mg?) How many pills do you take daily? Please tell us about the Pharmacy where you usually fill your prescriptions. This information may allow us to send prescription and refill information electronically to your pharmacy. Pharmacy Name: Tel. number:_ Street address City: State: Zip: Please go to the next page... 5
6 Please indicate if you have any of the following symptoms: Stomach/Intestinal/Abdominal Discomfort Bowel problems Balance problems Dizziness Co-ordination problems Weakness/Paralysis Chest Pain Hearing loss Ringing in Ears Vision problems Memory difficulty Numbness/Tingling Neck Pain Back Pain Joint Pain Arm/Leg Pain Restless Legs Movement/Tremor Speech Difficulty Swallowing Shortness of breath Weight Gain or Loss Skin Changes/Rash Depression Anxiety Impotence Bladder problems Speech difficulty Swallowing difficulty Snoring Unusual Behaviors/Symptoms During Sleep Insomnia Pain in legs when you walk Please go to the next page... 6
7 Please give us the following information if you have had any of these tests: Test When Where (approximate date) (location where test was done) CT Scan EMG Holter EKG (24 hr) MRI EEG Spinal tap Angiogram Myelogram 7
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