Plaza 2
1301 South Cliff Avenue, Suite 400
Sioux Falls SD 57105
Name_______________________________________________ Today’s Date_______________________________
Age______________________ Birthdate__________________ Date of last physical exam_____________________
Are you presently under a physician’s care for any condition? q Yes q No
If yes, please state condition_____________________________ Name of physician___________________________
What is the reason for today’s visit?__________________________________________________________________ SYMPTOMS Check (✓) symptoms you currently have or have had in the past year
CONSTITUTIONAL
qChills
qFainting
qFever
q Loss of sleep
q Loss of weight
qNervousness
qSweats
EARS, NOSE, THROAT, MOUTH
q Bleeding gums
q Difficulty swallowing
qEarache
q Ear discharge
qHoarseness
q Loss of hearing
qNosebleeds
q Ringing in ears
q Sinus problems
GU: MALES
qDischarge
q Testicular mass
q Testicular tenderness
SKIN
q Bruise easily
q Change in moles
qHives
qItching
qJaundice
qRash
qScars
q Sore won’t heal
GU: FEMALES
q Bleeding between periods
q Breast lump
q Extreme menstrual pain
q Hot flashes
q Nipple discharge
q Painful intercourse
q Vaginal discharge
CARDIOVASCULAR
q Chest pain
q Irregular heart beat
q High blood pressure
q Low blood pressure
q Poor circulation
q Rapid heart beat
q Swelling of ankles
q Varicose veins
NEUROLOGICAL
qDizziness
qForgetfulness
qHeadache
q Loss of consciousness
qNumbness
location___________________
qShaking
EYES
q Blurred vision
q Crossed eyes
q Double vision
qRedness
q Visual flashes/halos
qWatering
ALLERGIC/IMMUNOLOGIC
q Hay fever
GENITO-URINARY
q Blood in urine
q Frequent urination
q Lack of bladder control
q Painful urination
qUrgency
HEMATOLOGIC
q Bleeding disorders
Date of last menstrual period
____________________________
Pads/tampons per day___________
Douche: q yes q no
Date of last Pap smear__________
q normal q abnormal
Are you pregnant? q yes q no
Number of children_____________
Date of last mammogram________
ENDOCRINE
q Cold intolerance
qGoiter
q Growth changes
MUSCLE/JOINT/BONE
Pain, weakness, numbness in:
qArms
qHips
qBack
qLegs
qFeet
qNeck
qHands
qShoulders
qFracture__________________
GASTROINTESTINAL
q Appetite poor
qBloating
q Bowel habit changes
qConstipation
qDiarrhea
q Excessive hunger
q Excessive thirst
qGas
qHeartburn
qHemorrhoids
qIndigestion
qNausea
q Rectal bleeding
q Stomach pain
qVomiting
q Vomiting blood
OTHER (Please list):
____________________________
____________________________
____________________________
____________________________
____________________________
Date of last:
Colonoscopy:_______________
Chest X-ray:_______________
EKG:_____________________
RESPIRATORY
qAsthma
q Coughing up blood
q Difficulty breathing
q Persistent cough
qWheezing
CONDITIONS Check (✓) conditions you currently have or have had in the past year
qAbnormal pap
qAIDS
qAlcoholism
qAnemia
qAngina
qAnorexia
qArthritis
qAsthma
qBleeding disorders
qBlood clots
qBreast lump
qBronchitis
qBulimia
qCancer
qCataracts
qChem. dependency
qDiabetes
qEmphysema
qEpilepsy
qGlaucoma
qGoiter
qGonorrhea
qGout
qHeart Disease
qHeadaches
qHernia
qHerpes
qHepatitis
qHigh blood pressure
qHigh cholesterol
qHIV positive
qIrregular periods
qKidney disease
qLiver disease
qMigraines
qMiscarriage
qMultiple sclerosis
qPacemaker
qPneumonia
qPolio
qUrethral dis/inf
qVaginal infections
qOther (list):
__________________
__________________
__________________
__________________
__________________
__________________
__________________
qProstatitis
qPsychiatric care
qRheumatic fever
qSexual trans. dis
qStroke
qSuicide attempt
qThyroid problems
qTonsillitis
qTuberculosis
qUlcers
MEDICATIONS List medications you are currently taking (include dosage)
1.
2.
3.
4.
5.
6.
Pharmacy Name:
7.
8.
Phone number:
9.
10.
ALLERGIES or ADVERSE REACTIONS TO MEDICATIONS OR SUBSTANCES
1.
Form 7396-27 PS (Rev. 11/07)
2.
Health History
3.
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Plaza 2
1301 South Cliff Avenue, Suite 400
Sioux Falls SD 57105
FAMILY HISTORY (Complete health information about your family)
Check (✓) if your blood relatives had any of the following:
of Age at
Cause of death
Relation Age State
Disease
Relationship
✓
health death
Arthritis, Gout
Father
Asthma, Hay fever
Mother
Cancer, type___________
Brothers
Chemical Dependency
Diabetes
Sisters
High blood pressure; stroke
Heart disease
Kidney disease
Grandparents
PREGNANCY HISTORY (Include miscarriage, abortion, etc.)
SURGERIES / HOSPITALIZATIONS
Year
Hospital
Reason for surgery /
hospitalization
Year
of
Birth
Sex
of
Birth
Complication, if any
HEALTH HABITS (Check (✓) which substances you use and
Have you ever had a blood transfusion? q Yes
If yes, please give approximate date(s):
SERIOUS ILLNESS/INJURIES
q No
DATE OUTCOME
describe how much you use and/or how often habit is engaged in)
Caffeine
Drugs
Tobacco
Seatbelts
Exercise
OCCUPATIONAL CHOICES
Check (✓) if your work exposes you to the following
Stress
Hazardous Substances
Heavy Lifting
Other
What is your occupation?
Self breast exam
Self-testicular exam
Do you feel safe at home? q Yes q No
Are you sexually active? q Yes q No
Are you on birth control? q Yes q No
If yes, what type?
(Check (√) the disease against which you have been
immunized, and approximate date:
q Tetanus
q Smallpox
q Polio
q Other
q Influenza
q Typhoid
I certify the above information is correct to the best of my knowledge. I will not hold my doctor or any members of
his/her staff responsible for any errors or omissions I may have made in the completion of this form.
Signature of patient:_____________________________________________________ Date:__________________
Signature of physician/nurse practitioner_____________________________________ Date:__________________ Form 7396-27 PS (Rev. 11/07)
Health History
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