PATIENT’S MEDICAL HISTORY
Patient Name: _______________________________________
Circle any symptoms or illnesses which have incurred in the past five years, any which have significant impact on your health (such as chronic disease or disability), or any which may affect this hospitalization/ surgery.
General Normal Endocrine Normal Back Normal Fever Thyroid trouble Back ache stiffness Weight loss Diabetes Back injury Fatigue Heat or cold intolerance Depression Excessive sweating Nervousness Excessive thirst or hunger Trouble sleeping Excessive urination
Head Normal Heart Normal Arms and Legs Normal Headache High blood pressure Joint pain or injury Head injury Heart attack Weakness Rheumatic fever Paralysis Heart murmur Tremors Chest pain or angina Numbness or tingling Palpitations Swelling Arthritis Gout Cramps
Eyes Normal Lungs Normal Neurologic Normal Poor vision Trouble breathing Stroke Wear glasses or contact Cough Paralysis Pain Spitting up blood Seizure disorder Double vision Wheezing Memory disorder Glaucoma Asthma Fainting Cataracts Bronchitis Tremors Emphysema Pneumonia Tuberculosis
Ears Normal Digestive Normal Bleeding Normal Poor hearing Trouble swallowing Easy bruising Wear hearing aid Heartburn or ulcer Prolonged bleeding from cuts Pain Nausea Frequent nose bleeds Drainage Vomiting Bleeding from teeth and gums Noises or tinnitus Diarrhea Blood in urine and stool Balance trouble or vertigo Constipation Heavy menstrual flow Rectal bleeding Anemia Hemorrhoids Blood transfusion
Nose and throat Normal Liver Normal Reproductive Normal Frequent sore throat Jaundice Sexually transmitted disease Hoarseness Hepatitis Nasal stuffiness Gall stones Gynecology Normal Nasal allergies Pregnant Nose bleeds Last menstrual period Sinus trouble Date______________ Snoring
Neck Normal Urinary Normal Habits Normal Swollen glands Difficulty urinating Tobacco use ____ packs/ days Goiter Bloody urine Alcohol use ____ oz/ days Neck pain Kidney stones Coffee or tea use Trouble moving neck Kidney failure Aspirin use Trouble swallowing Hemodialysis ___ note amount if used regularly
Other Normal Intravenous drug use Substance abuse