Patient History and Doctor NotesPlease Fill Out The Form Patient History and Doctor NotesSocial HistoryDo you drink alcohol? Yes NoHow many per week?Do you or have you ever smoked or chewed tobacco? Yes NoPacks per day?Quit?When?o you or have you ever used recreational drugs? Yes NoType?Do you drink caffeine daily? Yes NoHow much?Do you exercise regularly? Yes NoHow often?Are you married? Yes NoDo you have children/dependents at home? Yes NoHow many?Do you have a living will or advance directives? Yes NoWhat is your highest level of education?Review of SymptomsPlease check any of the following that you recently experiencedGeneral Fatigue Fever Hopelessness Hot flashes Night sweatsSkin Recent weight loss or gain Change in pigmentation Hives Itching RashesENT Change in vision/hearing Congested nose Ringing in ears Ear discharge Hearing loss Nose bleeds Chronic sinus problemsBreast Lumps in breast Nipple discharge Erosion around nipple areaRespiratory Difficulty breathing Frequent cold/coughing Shortness of breathingCardiac Chest pain Difficult walking 2 blocks Palpitations Swelling of the feet/anklesGastrointestinal Abdominal pain/cramping Blood or black stool Change in the bowel habits or appetite Frequent diarrhea Frequent heartburn /gas / bloating Vomiting blood Nausea Difficulty swallowingGenitourinary Difficulty urinating Frequent urination Loss of bladder control Burning urination Vaginal discharge Change in urine stream/ smell/ colorMusculoskeletal Joint pain or swelling Difficulty walking Muscle cramping or weaknessNeuropsychiatric Prior treatment for depression/psychiatric care Fainting spells, Convulsions Headaches Dizziness Poor concentration Loss of interest in daily activities Difficulty sleepingHematologic Easy bruising Excessive bleeding after cuts low healing after cuts Lumps in armpit or groin areaSubmit Form
