FORM #8 - MEDICAL HEALTH HISTORY FORM This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. Step 1 of 9 0% Patient's Name* First Last Date* MM slash DD slash YYYY Gender* Male Female SymptomsCheck symptoms you currently have or have had in the past.Have you shown any symptoms recently or in the past?* Yes No General Chills Depression Dizziness Fainting Fever Forgetfulness Headache Loss of Weight Nervousness Sweats Please state if any of these symptoms were fairly recent. Muscle / Joint / Bone Arm Hips Back Legs Feet Neck Shoulders Hands Eye / Ear / Nose / Throat Bleeding Gums Blurred Vision Crossed Eyes Difficult Swallowing Double Vision Earache Hay Fever Hoarseness Loss of Hearing Nosebleeds Persistent Cough Ringing in Ears Sinus Problems Vision Flashes Vision Halos Skin Bruise Easily Hives Itching Change in Moles Rash Scars Sore that won’t Heal Gastrointestional Poor Appetite Bloating Bowel Changes Constipation Diarrhea Excess Thirst Gas Hemorrhoids Indigestion Nausea Rectal Bleeding Stomach Pain Vomiting Blood in Vomit Cardiovascular Chest Pain High Blood Pressure Irregular Heart Beat Low Blood Pressure Poor Circulation Rapid Heartbeat Swelling of Ankles / Feet Varicose Veins Genito-urinary Blood in Urine Frequent Urination Painful Urination Lack of Bladder Control Men Only Breast Lumps Erection Difficulty Lump in Testicles Penis Discharge Sore on the Penis This section must only be used by male patients Women Only Breast Lumps Abdominal Pap Smear Bleeding between Periods Extreme Menstrual Pain Hot Flashes Nipple Discharge Painful Intercourse Vaginal Discharge This section must only be used by female patientsDate of Last Period MM slash DD slash YYYY Date of Last Pap Smear MM slash DD slash YYYY Have you had a Mammogram? Yes No Date of Mammogram MM slash DD slash YYYY Are you Pregnant? Yes No Number of Children if any*Number of Vaginal Birth*Number of C-Sections* ConditionsCheck conditions you currently have or have had in the past year AIDS Appendicitis Alcoholism Anemia Anorexia Arthritis Asthma Bleeding Disorder Breast Lumps Bronchitis Bulimia Cancer Cataracts COPD Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Glaucoma Goiter Gonorrhea Gout Heart Disease Hepatitis Hernia Herpes Hypertension High Cholesterol HIV Positive Kidney Disease Liver Disease Measles Migraines Miscarriage Mononucleosis Multiple Sclerosis Mumps Pacemaker Pneumonia Polio Headaches Scarlet Fever Stroke Suicide Attempt Thyroid Problem Tonsillitis Tuberculosis Typhoid Fever Ulcers Vaginal Infections Venereal Disease Heart Failure Please indicate below why you cannot go to an office or outpatient facility for care?* Family Health History HospitalizationDate MM slash DD slash YYYY Hospital Reason for Hospitalization & Outcome Were there any complications? Yes No If yes, please state.* Health HabitsDo you use or consume any the following? Caffeine Tobacco Drugs Other How much? Occupational ConcernsDoes your work require or result to any of the following? Stress Hazard Material Heavy Lifting Other Serious Illness & InjuriesHave you had any serious illnesses or injuries* Yes No Please, describe the nature of the illness/injuries*Date* MM slash DD slash YYYY Outcome* Please, list all current medications*Name of MedicationDose TakenFrequencyReason for medicationPrescriber If none, please enter N/A. Use the + icon on right side to add more rows.Pharmacy Name Pharmacy TelephonePlease, state any allergies you might have.*If none, enter N/AEmailThis field is for validation purposes and should be left unchanged. Δ
