Nome: Dote: Birthdote: Age: Dote of lost physicol exominotion: Occupotion: Reoson for visit todoy: MEDICATIONS List ollmedicotions you ore currently toking i/tEDlCA[ HISTORY Check ( /l the medicol conditions you hove or hove hod in the post. I AIDS E Alcoholism n Anemio fl Anorexio E Appendicitis n Arhritis fl Asthmo D Bleeding Disorders [J Breost Lump E Bronchitis fl Bulimio fJ Concer D Cotorocts [J ChemicolDependency E Chicken Pox E Diobetes fl Emphysemo D Epilepsy E GollBlodder Diseose fl Gloucomo E Goiter [] Gonorrheo E Gout n Heort Diseose E Hepotitis [] Hernio o lJ Herpes E High Cholesterol E HIV Posilive [3 Kidney Diseose D liver Diseose fl Meosles E Migroine Heodoches [l Miscorrioge fl lvlononucleosis I Muhiple Sclerosis D Mumps fl Pocemoker fl Pneumonio E Polio n Proslote Problem fl Psychiotric Core fl Rheumotic Fever I Scorlet Fever E Stroke D Suicide Atiempt [J Thyroid Problems E Tonsillitis [] Tuberculosis D Typhoid Fever n Ukers E Voginollnfections D VenereolDiseose SYMPTOII S Check ( ,/ ) symptoms you currently hove or hore hod in the post yeor. GENERAT X Chills [J Depression fl Dizziness n Fointing f] Fever I Forgetfulness E Heodoche E Loss o[ sleep n Loss o[ *eight [--] Nervousness n Numbness [-: Sweots MUSCTEIJOTNT/BONE Poin, weokness, numbness in: GASTROINTESTINAT E Appetite poor [I Blooting [l Bowel chonges n Constipotion D Diorrheo f] Excessive hunger fl Excessive thirst n Gos n Hemorrhoids I lndigestion I Nouseo E Rectolbleeding E Stomoch poin n Vomiting fl Vomiting blood CARDIOVASCULAR [J Lhest porn u High blood pressure I lrregulor heort beoi E Low blood pressure n Poor circulotion [I Ropid heort beot n Swelling of onkles fI Voricose veins EYE, EAR, NOSE, THROAT E Bleeding gums E Blurred vision fl Crossed eyes E Difficulty swollowing E Double vision Ll Eoroche n Eor dischorge n Hoy lever n Hoorseness n Loss of heoring I Nosebleeds E Persistent cough E Ringing in eors fl Sinus problems fl Vision - Floshes E Vision - Holos SKIN I Bruise eosily E Hives n ltching tl Chonge in moles n Rosh n Scors [] Sores thot won't heol MEN only [J Breost lump E Erection difficulties D Lump in testicles [l Penis dischorge fl Sore on penis n Other WOMEN only [] AbnormolPop Smeor I Bleeding beh,veen periods I Breost lump E Extreme menstruol poin n Hotfloshes rl Nipple dischorge D Poinful lntercourse [J Voginoldischorge n other Dote of lost menstruol period Dote o[ lost Pop Smeor Hove you hod ^ o mommogromg Are you pregnont? Number of children [] Arms E Bock I Feet [] Honds [J Hips n Legs U Neck E Shoulders GENITO.URINARY I Blood in urine E Frequent urinstion D Lock of blodder control E Poinfulurinotion