LAKERIDGEINTERNAL
MEDICINE,
PC
1 3 0 0 1 S u m m i t S c h o o lR o a d ,S u i t e 2
W o o d b r i d g eV, A 2 2 1 9 2
Dateof last physicalexamination
What is your reasonfor visit?
youcurrentlyhaveor havehadin thepastyear.
Check(/) conditions
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f,
n
n
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n
n
I
MUSCLE/JOINT/BONEn
Pain,weakness,
numbness
in: I
fl Hips
n tums
[] Legs
n Back
n Neck
n Feet
I
n Hands fl Shoulders I
I
GENIT0-URINARY I
n
n gloodin urine
urination
n Frequent
!
control
n Lackof bladder
n
GASTROINTESTINAL EYE,EAR,NOSE,THROAT
gums
poor
Appetite
I Bleeding
Bloating
n Blurredvision
Bowelchanges
eyes
! Crossed
Constipation
I nifficultyswallowing
Diarrhea
vision
! Double
Excessive
hunger
n Earache
Excessive
thirst
n Bardischarge
Cas
fl Hayfever
Hemorrhoids
! Hoarseness
Indigestion
I Lossofhearing
Nausea
n Nosebleeds
Rectalbleeding
cough
I Persistent
pain
Stomach
n Ringingin ears
Vomiting
n Sinusproblems
Vomitingblood
! Vision- Flashes
n Vision- Halos
CARDIOVASCULAR
Chestpain
SKIN
Highbloodpressure
n Bruiseeasily
Irregularheartbeat
fl Hives
Lowbloodpressure
n ttching
Poorcirculation
in moles
n Change
Rapidheartbeat
n Rash
Swelling
of ankles
I Scars
n Painfulurination
Varicoseveins
n
f]
n
n
n
n
I
!
n
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fl
!
GENERAL
CniUs
Depression
Dizziness
Fainting
Fever
Forgetfulness
Headache
Lossofsleep
Lossofweight
Nervousness
Numbness
Sweats
I
I
Sorethat won't heal
f]
n
D
I
n
n
MENonly
Breastlump
Erectiondifficulties
Lumpin testicles
Penisdischarge
Soreonpenis
Other
WOIvIENonly
PapSmear
I Abnormal
Bleedin$betweenperiods
I
! Breastlump
pain
menstrual
I Extreme
Hot
flashes
!
f, Nippledischarge
I Painfulintercourse
discharge
I Vaginal
fl Other
Dateof last
period
menstrual
Dateof last
PapSmear
Haveyouhad
a mammogram?Are you pregnant?
Numberof children
Check(/) conditionsyou currentlyhaveor havehadin the pastyear.
E ems
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I
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n
Alcoholism
Anemia
Anorexia
Appendicitis
n
n
fJ
fl
n
n
!
n
Arthritis
Asthma
Disorders
Bleeding
BreastLump
Bronchitis
Bulimia
Cancer
Cahracts
n
!
!
n
I
I
n
n
n
fl
fl
n
n
Chemical
Dependency
chickenPox
Diabetes
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
HeartDisease
Hepatitis
Hernia
Herpes
fl
n
[1
I
n
n
!
fl
fJ
n
fl
!
n
HigtrCholesterol
Hry Positive
KidneyDisease
LiverDisease
Measles
Migraine
Headaches
Miscarriage
Mononucleosis
t{ultipleSclerosis
Mumps
Pacemaker
Pneumonia
Pofio
fl
n
fl
n
fJ
I
fl
I
I
!
I
I
I
Prostate
Problem
Psychiatric
Care
Rheumatic
Fever
ScarletFever
Stroke
Suicide
Attempt
ThyroidProblems
Tonsillitis
Tuberculosis
Typhoid
Fever
ulcers
VaginalInfections
Disease
Venereal