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

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

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______________

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