Home Directions Newsletters

Name: Marital Status: Date: Age:
Occupation: Referred By:
Birth Date: Number of Children:
Home Telephone: Work Telephone:
 
Family History - Consider Grandparents, Parents, and Siblings
  Relative with Disease Current Age or Age and Cause of Death
Allergy-Asthma
Alcohol Abuse
Arthritis
Blood Disorders
Cancer and Type
Diabetes
Epilepsy
Heart Disease
High Blood Pressure
Psychiatric Problems
Stroke
Tuberculosis
Other
Serious Illness not Mentioned Above:
List all Medicines Currently Used, Doses and Non Prescription Drugs:
Allergies: List all Known Especially to Medicines
 
Please List the Year of Your Most Recent:
TB Skin Test: X-Ray: Prostate Exam:
Chest X-Ray: EKG: PAP Smear:
Tetanus Shot:
 
Habits Yes No If Yes Describe
Smoking
Alcohol
Coffee or Tea
Other Drugs Used
Exercise
Special Interests or Hobbies
 
Please check any item that applies to you currently or in the past.
Weight gain or loss Recurrent abdominal pain
Unusual fatigue Ulcers
Sleep problems Black or bloody stools
Disabled Heartburn
Hepatitis Gallbladder
Rheumatic Fever Change in appetite
Tuberculosis Swallowing problems
Venereal Disease Hernia
Asthma Hemorrhoids
Eczema Polyps
Sinus infection Vomited blood
Hay fever MALES ONLY
Hives     Change in urine stream
Diabetes     Prostate trouble
High cholesterol     Lumps on testicles
Thyroid trouble     Sexual dysfunction
Anemia FEMALES ONLY
Bleeding or bruising     Menstrual trouble
Growing moles/lumps     Vaginal discharge
Other skin problems     Abnormal bleeding
Do you wear glasses     Tubal infection
Glaucoma     Infertility
Other eye problems     Breast lumps or pain
Hearing difficulties     Sexual concerns
Ringing ears     Age of first period
Dizziness     Number of pregnancies
Motion sickness     Miscarriages or abortions
Dental problems     Caesarean sections
    Last dental appt.     Type of birth control
High blood pressure Arthritis or grout
Heart disease or murmur Bursitis
Chest pain Fractured bones
Racing/pounding heart Back trouble
Ankle swelling Headaches
Shortness of breath Seizures
Lung/breathing problem Tremor
Cough Fainting
Pneumonia Speech problems
More frequent urination Weakness or paralysis
Urinating blood/pain Coordination problems
Leaking urine Memory or thinking problem
Urinating often at night Bowel control problems
Kidney or bladder infections Stroke or TIA's
Kidney stones Other
 
Patient Name: Birth Date:
 
Home · Directions · Newsletters · Privacy Policy
Copyright © 2004 - 2006 Timberline Medical, LLC, All rights reserved
Created by Ontare Solutions