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General information
Patient History
Current medication
Allergies
  Family History
  Father Mother Children Siblings Father’s
Parents		 Mother’s
Parents
  Alcoholism
  Asthma
  Bleeding Disorder
  Cancer
  Diabetes
  Glaucoma
  Epilepsy/Convulsions
  Heart Disease
  High Blood pressure
  Kidney Disease
  Mental Illness
  Migrain
  Osteoporosis
  Stroke
  Thyroid Disease
  Other:   
Habits
 Alcohol:
  Type:  
  Amount:  
 Diet:
  Salt Intake:  
  Fat Intake:  
  Other:  
 Sleep:
      Difficulty Falling Asleep     Continuity Disturbances
   Early Morning Awakening     Daytime Drowsiness
 Other...  
 Smoke:
  Packs Daily:  
  How Long?  
 Exercise:
  Routine:  
 
 Coffee:
  Cups Daily:  
  Other Caffine:  
Medical History
 Ringing in Ear    Diverticulosis    Bone Fracture / Joint Injury  
 Ear Infections- Frequent    Crohn’s / Colitis    Gout  
 Diziness / fainting    Hemorrhoids    Foot Pain  
 Failing Vision    Hernia    Cold Numb Feet  
 Eye Infections    Urine Infections - Frequent    Rashes  
 Nose Bleeds    Blood In Urine    Hives  
 Sinus Trouble    Urination    Psoriasis  
 Sore Throats-frequent       Overnight more than twice    Eczema  
 Hayfever / Allergies       Painful    Nervousness  
 Pneumonia       Loss of Control    Depression  
 Bronchitis / Chronic Cough       Decrease in Force / Flow    Memory Loss  
 Asthma / Wheezing    Kidney Stones    Moodiness - Excessive  
 Chest Pain    Veneral Disease    Phobias  
 High Blood Pressure    Urethral Discharge    Mental Illness  
 Heart Murmur    Chronic Fatigue    Lactose Intolerance  
 Swollen Ankles    Weight Loss - Recent    Prostate Disease  
 Leg Pain- Walking    Anemia    Sexual / Menstrual Dysfunction  
 Varicose veins / Phlebitis    Bruise easily    Frequent Infections  
 Loss of Appetite    Cancer    Diphtheria  
 Difficulty Swallowing    Diabetes    Tetanus  
 Indigestion or Heartburn    Thyroid Disease    Chicken pox  
 Persistent Nausea / Vomiting    Convulsions / Seizures    Polio  
 Peptic Ulcers    Stroke    Mumps  
 Abdominal Pain - Chronic    Tremors / Hands Shaking    Measles  
 Gall Bladder Trouble    Muscle Weakness    Rubella  
 Jaundice / Hepatitus    Numbness / Tingling Sensations    Rheumatic Fever  
 Change in Bowel Habits    Headaches - Frequent    Scarlett Fever  
 Diarrhea    Arthritis / Rheumatism    Turberculosis  
 Constipation    Osteoporosis    Herpes  
 Bloody or Tarry Stools    Back Pain - Recurrent    Other:    
  Females - Please Complete
  Menstrual Flow:   Regular Irregular
    Pain / Cramps
 
  Date:    (first day of last period) 
  Flow:    (days of flow) 
  Cycle:    (length of cycle - days) 
  Pain / Beeding during or after sex?   yes  no
  Are you Pregnant?   yes  no
  Planning Pregnancy?   yes  no
Phyisical
  Weight:   lbs.
  Height:  
  Blood Pressure:  
  Year of last Exam:   (with blood test)

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