Waugh Chapel Family Medicine
410-721-1507
David G. Freas, MD Ian M. Shantz, MD
Confidential Record:
Information contained will not be released except when you authorize us to do
so
MR#
NAME: DATE:
Last
First MI
My last complete physical exam was done in (year) by
Family History:
|
Family History |
Year of Birth |
Illnesses |
Age at Death |
Cause of Death |
|
|
Father |
|
|
|
|
|
|
Mother |
|
|
|
|
|
|
Brothers/Sisters |
|||||
|
#1 |
M or F |
|
|
|
|
|
#2 |
M or F |
|
|
|
|
|
#3 |
M or F |
|
|
|
|
|
#4 |
M or F |
|
|
|
|
|
#5 |
M or F |
|
|
|
|
|
Children |
|||||
|
#1 |
M or F |
|
|
|
|
|
#2 |
M or F |
|
|
|
|
|
#3 |
M or F |
|
|
|
|
|
#4 |
M or F |
|
|
|
|
|
#5 |
M or F |
|
|
|
|
o
More siblings/children
listed on attached sheet
Check if you or any close
blood relatives (other than those
mentioned above) have or had any of the following:
|
o
Heart disease |
o
Unusual bleeding after |
o
Depression/Nervous
Breakdown |
|
o
Stroke |
surgery or dental work |
o
Alcoholism |
|
o
High blood pressure |
o
Asthma |
o
Migraine headaches |
|
o
High cholesterol |
o
Stomach or intestinal
problems |
o
Arthritis |
|
o
Diabetes |
o
Thyroid disease |
o
Kidney disease |
|
o
Cancer/Tumor |
o
Epilepsy |
o
HIV Infection |
Past Medical History:
Surgeries/Hospitalizations (women exclude normal deliveries):
List any other serious illnesses or injuries you have
had:
Patient Personal History (cont’d)
|
Prescription Medications Over-the-counter Drugs Herbal Preparations |
Dose or Strength |
How often do you take this medication? |
How long have you been taking this medication? |
What do you take this medication for? |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
o
More medications listed
on attached sheet
Medication allergies:
_________________________________________________________________
Other allergies: ______________________________________________________________________
Potential areas for stress:
Where do you work? ________________________________ What is your
occupation? ____________________
Who lives in your household?
__________________________________________________________________
Any marital problems?
________________________________________________________________________
Does anyone in your household have drug or alcohol problems? _______________________________________
What are your biggest life stressors at this time?
____________________________________________________
Recreation:
What do you do for recreation/relaxation?
_________________________________________________________
|
Habits/Risk Factors: Tobacco use: o
Don’t smoke or use
tobacco o
Age started _______
Age stopped ______ o
Cigarettes ______ Cigars _____ Pipe _____ o
Smokeless
tobacco/snuff ˇ
How Long ________ |
Coffee/Tea/Soda o
Cups per day ______ o
Caffeinated o
Decaffeinated |
|
Alcohol use: o
None o
Seldom o
Regularly o
Occasionally excessive o
Have sought help |
Drug use: o
None o
Seldom o
Regularly o
Occasionally excessive o
Have sought help |
|
Sexuality o
Heterosexual
(straight) o
Homosexual (gay) o
Bisexual (both) |
Sexuality o
Multiple sexual
partners in last year o
Sexual partners who
had Hepatitis B, were intravenous drug users or prostitutes |
|
Safety: o
Use seat belts in
vehicles o
Smoke detectors in
home o
Carbon monoxide
detectors in home |
Exercise: o
Exercise regularly o
________
times per week |
Patient Name ______________________________ Date of Birth ____________
Habit/Risk Factors
|
o
History of working in
mines o
Current or past
exposure to a lot of dust, asbestos or chemicals |
|
REVIEW OF SYSTEMS: Please check any conditions you are experiencing
or have experienced.
|
Constitutional: o
Unexplained weight
loss o
Change in appetite o
Sleeping difficulty o
Fever/sweats o
Loss of energy |
Genito-urinary (GU) o
Burning or pain with
urination o
Increased frequency of
urination o
How often do you get
up at night to urinate? ___ times o
Unable to control
bladder o
Blood in urine o
Unable to start stream
or weak stream o
Any venereal/sexually
transmitted disease o
Kidney stones |
|
Skin o
Rashes or changes in
color o
Persistent itching o
Moles that have
changed o
Bruise easily |
Musculo-skeletal: o
Pain in bones or
joints o
Muscle pain o
Joints that swell o
Phlebitis or inflamed
leg veins |
|
Eyes: o
Loss of vision o
Blurring or double
vision o
Eye pain |
Endocrine: o
Thyroid problems |
|
Ears, Nose and Throat (ENT) o
Hearing loss o
Ringing in ears o
Ear pain o
Frequent nosebleeds o
Sinus trouble o
Constant nasal
congestion or runniness o
Persistent sore throat o
Voice changes or
hoarseness o
Trouble swallowing
bleeding gums |
Gastrointestinal (GI) o
Nausea/vomiting o
Vomited blood or
“coffee ground” material o
Heartburn or
indigestion o
Abdominal pain o
Constipation or
diarrhea o
Bloody or black bowel
movement o
Changes in bowel
movements o
Pain during or after
bowel movement yellow jaundice o
Hemorrhoids |
|
Respiratory: o
Chronic cough o
Wheezing o
Blood in sputum/phlegm o
Exposure to TB o
Positive TB test o
Shortness of breath ˇ
Doing you usual work ˇ
Climbing a flight of
stairs ˇ
Awakens you at night ˇ
Causes you to cough ˇ
Accompanied by
wheezing |
Cardiovascular: o
Pain, tightness or heaviness
in your chest ˇ
When exerting yourself ˇ
When upset or excited ˇ
Radiates down the arm ˇ
Disappears if you rest o
Rapid, slow or
irregular pulse o
Sleep on more than one
pillow o
Rheumatic fever/heart
murmur o
Calf pain when walking o
Ankle swelling |
|
Neurologic: o
Dizzy spells o
Recurrent headaches o
Memory loss o
Seizures or
convulsions o
Blindness of one eye o
Weakness in any part
of your body o
Numbness in any part
of your body |
Emotional: o
Feel nervous often o
Feel “down in the
dumps” often o
Worry a lot o
Loss of interests o
Loss of energy or
ambition o
Considered suicide o
Rate sex life
Poor 1
2 3 4 5 Excellent |
|
Other: o
Anemia |
Women: o
Last period
______________ o
Last Pap smear
_____________ o
Last mammogram
_______________ o
Diminished sexual
activity o
Bleeding after
intercourse o
Pain with intercourse o
Difficulties with
periods o
Recent vaginal
discharge o
Current method of
birth control _____ o
Number of pregnancies
_____ o
Number of miscarriages
______ o
Number of live births
______ o
Bleeding after
menopause o
Hot flashes o
Breast lump o
Breast pain |
|
Men: o
Diminished sexual
activity o
Discharge from penis o
Hernia o
Prostate trouble |
Preventive Medicine
|
Immunizations: I had my last vaccine in (please enter year): o
Tetanus ___________ o
Pneumonia ___________ o
Hepatitis A ___________ o
Hepatitis B
___________ |
Screening Exams: I had the following screening exams in (please enter
year): o
Bone density _________ o
Colonoscopy/colon
cancer screening _______ o
Prostate cancer
screening (men only) _______ o
Dental exam __________ |
Describe briefly your present medical problems and symptoms:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Patient’s Signature Date