Abnormal - Dr. Jeffrey Ries D.O. · PDF filejeffrey d. ries, d.o. 1310 san bernardino road, # 101 upland, ca 91786 (909) 579-0779 210 fwy 10 fwy 60 fwy foothill blvd e. arrow hwy san

Cardiovascular 

Abnormal Electrocardiogram  Aortic Stenosis  Atrial fibrillation  Cardiac arrest  Chest pain   Congestive heart failure  Heart valve replacement  Hypertension  Murmur  Heart attack  Palpitations  Peripheral vascular disease  Pulmonary embolism  Faint  Ventricular septal defect 

Respiratory 

Asthma  Bronchitis, chronic  Cough  Emphysema  Lung Cancer  Pneumonia  Shortness of breath  Sinusitis, chronic 

Digestive 

Appendicitis  Blood in stool  Colon cancer  Constipation  Diarrhea  Diverticula of intestine  Esophageal reflux  Heartburn  Hemorrhoids  Hepatitis  Hernia  Incontinence of feces  Intestinal obstruction  Irritable bowel syndrome  Liver disorder  Nausea  Nausea with vomiting  Peptic ulcer  Rectal bleeding  Vomiting 

Endocrine/Metabolic/Immune 

Type I Diabetes insulin use  Type II Diabetes non‐insulin  High cholesterol  High thyroid  Low thyroid  Pituitary gland disorder 

Vitamin deficiency  Weight gain, abnormal  Weight loss 

Neurologic 

Alzheimer’s disease  Convulsions  CVA  cerebrovascular accident  Gait abnormality  Headache  Hemipelgia  Lack of coordination  Meningitis  Migraine  Multiple Sclerosis  Neuropathy  Numbness  Parkinson’s Disease  Post stroke paralysis  Speech disturbance 

Renal/GU 

Bladder disorder  Kidney stone  Painful urination  ESRD  End stage renal disease  Family history of Prostate cancer  Blood in urine  Impotence cause undetermined 

Prostate cancer  Prostatic hypertrophy benign  Urinary incontinence 

Hematologic 

Anemia  Leukemia  Transfusion reaction 

Musculoskeletal 

Arthritis rheumatoid  Backache  Bone infection  Bunion  Bursitis  Connective tissue disease  Ganglion  Joint pain  Muscle spasm  Osteoporosis  Rotator cuff syndrome of shoulder 

Sciatica  Breast 

Abnormal mammogram  Breast mass  Nipple discharge 

Skin 

Basal cell carcinoma  Cellulitis and abscess  Contact dermatitis  Edema  Malignant melanoma   Skin disorder 

Psychiatry 

Alcohol withdrawal  Anxiety disorder  Bipolar disorder  Insomnia  Major depression recurrent  Major depression single episode  Mental retardation  Panic disorder  Schizophrenia 

Gynecologic 

Abnormal PAP smear  Cervical cancer  Hormone replacement therapy  Menopausal syndrome  Pelvic pain  Polycystic ovaries 

Obstetric 

Diabetes gestational  Infertility  Spontaneous abortion  Tubal pregnancy 

Injury/Poisoning 

Concussion  Fracture  Head injury  Head injury, closed  Motor Vehicle Accident  Nerve injury 

  Never  Current  Former 

Tobacco       

Alcohol       

Illegal Drugs       

Patient Medical History Name:_________________________ 

Have you ever had a blood transfusion? Yes  No 

If yes approx. dates: _______________ 

Cardiovascular 

Abdominal aneurysm _____________________________  

CVA ___________________________________________ 

Family history non‐contributory _________________________ 

Heart disease ___________________________________ 

Hyperlipidemia __________________________________ 

Hypertension ___________________________________ 

Sudden death ___________________________________ 

Syncope  faint __________________________________ 

Transient Ischemic Attack  TIA ___________________________ 

Endocrine 

Diabetes Type I __________________________________ 

Diabetes Type II _________________________________ 

Hyperthyroidism ________________________________ 

Hypothyroidism _________________________________ 

Morbid obesity __________________________________ 

Neurologic 

Alzheimer’s disease ______________________________ 

Chorea ________________________________________ 

Common migraine _______________________________ 

Convulsions ____________________________________ 

Gait abnormality ________________________________ 

Hearing loss ____________________________________ 

Huntington’s disease _____________________________ 

Involuntary movement disorder _________________________ 

Meningitis _____________________________________ 

Motor neuron disease _________________________________ 

Multiple Sclerosis ________________________________ 

Neuropathy ____________________________________ 

Parkinson’s disease ______________________________ 

Spinal cord disease ____________________________________ 

Stroke _________________________________________ 

TIA ___________________________________________ 

Respiratory 

Asthma ________________________________________ 

Chronic bronchitis _______________________________ 

Emphysema ____________________________________ 

Lung disease ____________________________________ 

Lung cancer ____________________________________ 

Sleep apnea ____________________________________ 

Hematologic 

Anemia ________________________________________ 

Psychiatric 

Anxiety disorder _________________________________ 

Bipolar disorder _________________________________ 

Dementia conditions _____________________________ 

Depression _____________________________________ 

Psychiatric disorder ______________________________ 

Gastrointestinal 

Anus cancer ____________________________________ 

Colon cancer ___________________________________ 

Intestinal obstruction _____________________________ 

Liver disorder ___________________________________ 

Breast 

Breast cancer ___________________________________ 

Breast cyst _____________________________________ 

Cancer 

Cancer ________________________________________ 

Musculoskeletal 

Arthritis, rheumatoid _____________________________ 

Joint disorder ___________________________________ 

Muscle disorder _________________________________ 

Muscular dystrophy ______________________________ 

Family Medical HistoryPlease check all that apply. Use the line provided to add details of the family member and his/her current health. 

Please include maternal or paternal where appropriate. 

Hospitalizations/Surgeries Year       Hospital                    Reason for your Hospitalization/Surgery ______      ____________________________  _________________________________________________________ ______      ____________________________  _________________________________________________________ ______      ____________________________  _________________________________________________________ ______      ____________________________  _________________________________________________________

JEFFREY D. RIES, D.O. 1310 SAN BERNARDINO ROAD, # 101

UPLAND, CA 91786 (909) 579-0779

210 FWY

10 FWY

60 FWY

FOOTHILL BLVD

E. ARROW HWY

SAN ANTONIO HOSPITAL

N

IMPORTANT INFORMATION PLEASE READ

**Our suite is located through the glass door on the left end of the building (Note: bathrooms are located in the hall of the main building. There is no bathroom located in the office.) **Please bring a list of your current medications to your appointment **Please bring the films or CDs from any recent studies to your appointment. (If your studies were done at San Antonio Hospital, disregard this) **ALL PATIENTS ARE SUBJECT TO A 24 HOUR CANCELLATION FEE! SEE FINANCIAL POLICY FORM FOR MORE DETAILS. **Para nuestros pacientes que hablan solamente español, les agradeceriamos si pudieran traer un intreprete que hable ingles.