Patient Name:_________________________
Date:
/
/
Personal Health Inventory
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Associated signs/symptoms:
Main reason for today's visit
____________________________________________ ____________________________________________
(Are you having any other associated problems?)
(Why are you here?)
Describe your condition/concern
Quality:_____________________________________
(normal vs abnormal color, activity, etc)
Location:___________________________________ Duration:___________________________________
(Where is the pain/problem?)
(How long have you had it/when did it start?)
Severity:___________________________________ Context:____________________________________
(Rate your pain/problem from 1-5. 5 being the most severe)
Timing:____________________________________
(Does this pain/problem occur at a specific time?)
(Where were you when the problem started?)
Modifying factors:___________________________
(What makes it worse or better? Has it happened in the past?)
Medical History
Allergies
Previous Hospitalizations/Surgeries/
Serious Injuries/Trauma (Include dates)
_________________________________
_________________________________
_________________________________
_________________________________
Medications
_________________________________
_________________________________
_________________________________
_________________________________
History of adverse reaction to:
Penicillin or other antibiotics
Morphine, Demerol, or other narcotics
Novocain or other anaesthetics
Aspirin or other pain remedies
Tetanus antitoxin or other serums
Iodine, methiolate or other antiseptic
Other drugs/medications
Patient History
Use of alcohol:
Never
Rarely
Moderate
Daily
Use of tobacco:
Never
Previously but quit ________ Current packs per day ________
Use of drugs:
Never
Type/Frequency ________________
Excessive exposure at home or at work to:
Fumes
Dust
Solvents
Air-borne Particles
Noise
Family Medical History
Age
Diseases
If deceased, cause of death
Father
___ _____________________________________ ___________________
Mother
___ _____________________________________ ___________________
Siblings
___ _____________________________________ ___________________
___ _____________________________________ ___________________
___ _____________________________________ ___________________
Spouse
___ _____________________________________ ___________________
Children
___ _____________________________________ ___________________
___ _____________________________________ ___________________
Patient signature:___________________________
(Or responsible party)
Reviewed by: ______________________________
Date: / /
Personal Health Inventory
Please indicate your personal history [Y=Yes N=No O=Occasionally F=Frequently]
CONSTITUTIONAL SYMPTOMS
Good general health lately
Recent weight change
Fever
Fatigue
Headaches
EYES
Eye disease or injury
Wear glasses/contact lenses
Blurred or double vision
Glaucoma
EARS/NOSE/MOUTH/THROAT
Hearing loss or ringing
Earaches or drainage
Chronic sinus problem or rhinitis
Nose bleeds
Mouth sores
Bleeding gums
Bad breath or bad taste
Sore throat or voice change
Swollen glands in neck
CARDIOVASCULAR
Heart trouble
Chest pain or angina pectoris
Palpitation
Shortness of breath
while walking or lying flat
Swelling of feet, ankles or hands
RESPIRATORY
Chronic or frequent coughs
Spitting up blood
Shortness of breath
Asthma or Wheezing
GASTROINTESTINAL
Loss of appetite
Change in bowel movements
Nausea or vomiting
Diarrhoea
Painful bowel movements or constipation
Rectal bleeding or blood in stool
Abdominal pain
Peptic ulcer (stomach or duodenal)
GENITOURINARY
Frequent urination
Burning or painful urination
Blood in urine
Change in force of strain when urinating
Incontinence or dribbling
Kidney stones
Sexual difficulty
Male - testicle pain
Female - pain with periods
Reviewed by: ______________________________
Date: / /
Female
Female
Female
Female
Female
-
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irregular periods
vaginal discharge
# of pregnancies:______________________
# of miscarriages:______________________
date of last pap smear:
/
/
MUSCULOSKELETAL
Joint Pain
Joint stiffness or swelling
Weakness of muscles or joints
Muscle Pain or cramps
Back Pain
Cold extremities
Difficulty in walking
INTEGUMENTARY (skin, breast)
Rash or itching
Change in skin color
Change in hair or nails
Varicose Veins
Breast pain
Breast Lump
Breast discharge
NEUROLOGICAL
Frequent or recurring headaches
Light headed or dizzy
Convulsions or seizures
Numbness or tingling sensations
Tremors
Paralysis
Stroke
Head injury
PSYCHIATRIC
Memory loss or confusion
Nervousness
Depression
Insomnia
ENDOCRINE
Glandular or hormone problem
Thyroid disease
Diabetes
insulin
non insulin
Excessive thirst or urination
Heat or cold intolerance
Skin becoming dryer
Change in hat or glove size
HEMATOLOGIC/LYMPHATIC
Slow to heal after cuts
Bleeding or bruising tendency
Anaemia
Phlebitis
Past transfusion
Enlarged glands