603 28 1/4 Road
Grand Junction, CO 81506
(970) 263-2600
Review of Systems
Health History Sheet
Patient: _________________
DOB: ____________
Age: ______
Gender: M / F
Please mark any symptoms you are experiencing that are related to your complaint today:
Allergic/ Immunologic
Frequent Sneezing
Hives
Itching
Runny Nose
Sinus Pressure
Cardiovascular
Chest Pressure/Pain
Chest Pain on Exertion
Irregular Heart Beats
Lightheaded
Swelling (Edema)
Shortness of Breath
When Lying Down
Shortness of Breath
When Walking
Constitutional
Exercise Intolerance
Fatigue
Fever
Weight Gain (___lbs)
Weight Loss (___lbs)
Travel Within 10 Days
Where:
Eyes
Dry Eyes
Eye Irritation
Vision Changes
Psychiatric
Anxiety / Stress
Depression
Do Not Feel Safe in
Relationship
Mania
Sleep Problems
Ears/Nose/Mouth/Throat
Bleeding Gums
Difficulty Hearing
Dizziness
Dry Mouth
Ear Pain
Frequent Infections
Frequent Nosebleeds
Hoarseness
Mouth Breathing
Mouth Ulcers
Nose/Sinus Problems
Ringing in Ears
Endocrine
Increased Thirst /
Urination
Heat/Cold Intolerance
Gastrointestinal
Abdominal Pain
Black / Tarry Stool
Blood in Stool
Change in Appetite
Frequent Indigestion
Hemorrhoids
Trouble Swallowing
Vomiting
Constipation
Diarrhea
Nausea
Musculoskeletal
Back Pain
Joint Pain
Muscle Aches
Muscle Weakness
Genitourinary
Pain with Urinating
Blood in Urine
Difficulty Urinating
Incomplete Emptying
Urinary Frequency
Loss of Urinary Control
Hematologic / Lymphatic
Easy Bruising / Bleeding
Swollen Glands
Integumentary (Skin)
Changes in Moles
Dry Skin
Eczema
Growth / Lesions
Itching
Jaundice (Yellow
Skin or Eyes)
Rash
Respiratory
Cough
Coughing Up Blood
Shortness of Breath
Sleep Apnea
Snoring
Wheezing
Difficulty Breathing
Neurological
Dizziness
Fainting
Men Only
Pain/Lump in Testicle
Penile Itching,
Burning or Discharge
Problems Stopping or
Starting Urine Stream
Waking to Urinate at
Night
Sexual Problems /
Concerns
History of Sexually
Transmitted Diseases
Women Only
Bleeding Between
Periods
Heavy Periods
Extreme Menstrual Pain
Vaginal Itching,
Burning or Discharge
Waking to Urinate at
Night
Hot Flashes
Breast Lump
Breast Pain
Nipple Discharge
No Periods
Painful Intercourse
History of Sexually
Transmitted Diseases
Headaches / Migraines
Memory Loss
Numbness
Restless Legs
Seizures
Weakness
Are you sexually active?: Yes No
Current Sexual Partner Is: Female Male
Do you use condoms? Yes No
Method of Birth Control Used: ______________________
Women Only: Age of First Menstrual Period: ____________ Date of Last Menstrual Period: ____________
Age at Menopause: ____________
Number of Pregnancies: ____________
Live Births: ____________
Miscarriages: ____________
Abortions: ____________
Number of Cesarean Sections: ____________
603 28 1/4 Road
Grand Junction, CO 81506
(970) 263-2600
Health History, Page 1
Patient: ___________________
Please check any significant medical history in yourself or family members.
Condition
SELF
Father
Mother
Sibling
Alcoholism
Anemia
Anxiety
Arthritis
Asthma
Birth Defects
Blood Clots
Bowel Problems
Cancer - Type
Mother’s
Parent(s)
Father’s
Parent(s)
Details
COPD
Depression
Diabetes
Eye Disease
Epilepsy /
Seizures
Heart Attack
Heart Disease
Heart Murmur
Heartburn /
Reflux
High Blood
Pressure
High
Cholesterol
Kidney Disease
Liver Disease
Lung Disease
Mental Illness
Type:
Migraines
Stomach Ulcer
Stroke
Suicide / Suicide
Attempt
Thyroid Disease
Tuberculosis
Other:
Past Surgical History:
Surgery
Reason
Year
Hospital
603 28 1/4 Road
Grand Junction, CO 81506
(970) 263-2600
Health History, Page 2
Patient: ___________________
Allergies: List anything that you are allergic to (medications, food, bee stings, etc.) and how each affects you.
Allergy
Reaction
Medications: Please list all of the medications you are taking, including over-the-counter and vitamins.
Medication
Strength
Frequency Taken
Health Maintenance:
Test
Complete Physical
Colonoscopy
Lipid (Cholesterol)
Eye Exam
Bone Density
PSA (Men 50-70 y.o.)
PAP Smear (Women)
Mammogram (Women)
Immunization
Pneumonia Shot
Tetanus
Date
Date
Result (Please Circle)
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
Immunization
Date
Flu Shot
Zostavax (Shingles)
SOCIAL HISTORY:
Tobacco: _____ Current Every Day Smoker _____ Current Some Days Smoker
#_____ Packs Per Day
_____ Former Smoker
_____ Never a Smoker
_____ Use Chewing Tobacco
Alcohol Use:
No
Yes: How much per day?
Drug Use:
No
Yes: How much per day?
Exercise:
No
Yes: What kind of physical activity?
How often do you exercise?
Marital Status: ____ Single ____ Married ____ Separated ____ Divorced ____ Widowed
Level of School Completed:
Assignment of Benefits: I hereby assign to Grand Valley Primary Care any insurance or other third party benefits
available for health care services provided to me. I understand that Grand Valley Primary Care has the right to refuse or
accept assignment of such benefits. If these benefits are not assigned to Grand Valley Primary Care, I agree to forward
to the practice all health insurance and other third party payments I receive for services rendered to me immediately upon
receipt.
Signature of Patient/Legal Guardian: _____________________________ Date: _____________