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:
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Family History |
Year of Birth |
Illnesses |
Age at Death |
Cause of Death |
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Father |
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Mother |
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Brothers/Sisters |
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#1 |
M or F |
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#2 |
M or F |
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#3 |
M or F |
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#4 |
M or F |
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#5 |
M or F |
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Children |
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#1 |
M or F |
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#2 |
M or F |
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#3 |
M or F |
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#4 |
M or F |
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#5 |
M or F |
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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:
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o
Heart disease |
o
Unusual bleeding after |
o
Depression/Nervous
Breakdown |
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o
Stroke |
surgery or dental work |
o
Alcoholism |
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o
High blood pressure |
o
Asthma |
o
Migraine headaches |
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o
High cholesterol |
o
Stomach or intestinal
problems |
o
Arthritis |
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o
Diabetes |
o
Thyroid disease |
o
Kidney disease |
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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)
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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? |
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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?
_________________________________________________________
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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 ¡
How Long ________ |
Coffee/Tea/Soda o
Cups per day ______ o
Caffeinated o
Decaffeinated |
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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 |
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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 |
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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 |
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REVIEW OF SYSTEMS: Please check any conditions you are experiencing
or have experienced.
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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 |
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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 |
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Eyes: o
Loss of vision o
Blurring or double
vision o
Eye pain |
Endocrine: o
Thyroid problems |