PAGE 5 MEDICAL HISTORY PATIENT: _________________________ DATE: __________ ALCOHOL USE: NEVER 1 to 2 times per year 1 to 2 times per month 1 to 2 times per week Daily □ □ □ □ □ TOBACCO USE: Current Smoker Never Past Smoker; NOT NOW □ □ □ SUBSTANCE ABUSE: NEVER YES, SOMETIMES YES, IN THE PAST □ □ □ PHYSICAL EXERCISE: NEVER 1-2 times/week 3-4 times/week 5-6 times/week Daily □ □ □ □ □ RATE CONDITION OF HEALTH: CHECK ONE: EXCELLENT____ GOOD____ FAIR ____ POOR ____ □ □ ARE YOU SUBJECT TO PROLONGED BLEEDING? YES NO REVIEW OF SYSTEMS: (PLEASE REVIEW CHART BELOW AND CHECK THE BOXES THAT APPLY TO ANY HEALTH CONDITIONS THAT YOU MAY HAVE) MUSCULOSKELETAL RESPIRATORY ENDOCRINE □Coronary □Osteoarthritis □Asthma □Thyroid Artery Disease Disease □Hypertension □Osteoporosis □Emphysema/COPD □Diabetes 1 or 2 □High □Shortness Cholesterol of Breath ADDITIONAL ACTIVE MEDICAL ADDITIONAL ACTIVE OTHER: □Heart PROBLEMS: MEDICAL PROBLEMS: Murmur □Mitral Prolapse □High Blood Pressure __________________ □Palpitations/Fluttering of Heart _______________________________ □ Pacemaker □ Stent NEURO VASCULAR URINARY □NUMBNESS/TINGLING □Phlebitis □Blurry □Blood Vision in Urine □Seizure □Clotting/ □Hearing □Kidney Disorder Bleeding Problems Loss Stones □Tremors □Enlarged □Ringing □ Kidney Dialysis veins in legs in Ears □Stroke □Migraines □Leg cramps walking or at OTHER: night □Other: ___________________ ___________________________ SKIN GASTROINTESTINAL\ DIGESTIVE PSYCHIATRIC GENERAL □Rash □Anxiety □Cancer _________________ □REFLUX □Peptic Ulcer □Psoriasis □Depression □Redness/Heat of any □Hepatitis □Liver Disease joint? _________________ □MRSA □Chills □Stomach Problems □HIV/AIDS □ HISTORY OF GOUT
PAGE 5 MEDICAL HISTORY PATIENT: _________________________ DATE: __________ ALCOHOL USE: □ NEVER □ 1 to 2 times per year □ 1 to 2 times per month □ 1 to 2 times per week □ Daily TOBACCO USE: □ Current Smoker □ Never □ Past Smoker; NOT NOW SUBSTANCE ABUSE: □ NEVER □ YES, SOMETIMES □ YES, IN THE PAST PHYSICAL EXERCISE: □ NEVER □ 1-2 times/week □ 3-4 times/week □ 5-6 times/week □ Daily RATE CONDITION OF HEALTH: CHECK ONE: EXCELLENT____ GOOD____ FAIR ____ POOR ____ ARE YOU SUBJECT TO PROLONGED BLEEDING? □ YES □ NO REVIEW OF SYSTEMS: (PLEASE REVIEW CHART BELOW AND CHECK THE BOXES THAT APPLY TO ANY HEALTH CONDITIONS THAT YOU MAY HAVE) □Coronary Artery Disease □Hypertension □High Cholesterol □Heart Murmur □Mitral Prolapse □High Blood Pressure □Palpitations/Fluttering of Heart □ Pacemaker □ Stent MUSCULOSKELETAL □Osteoarthritis □Osteoporosis ADDITIONAL ACTIVE MEDICAL PROBLEMS: _______________________________ RESPIRATORY □Asthma □Emphysema/COPD □Shortness of Breath OTHER: ENDOCRINE □Thyroid Disease □Diabetes 1 or 2 ADDITIONAL ACTIVE MEDICAL PROBLEMS: NEURO □NUMBNESS/TINGLING □Seizure Disorder □Tremors □Stroke □Migraines □Other: ___________________ ___________________________ VASCULAR □Phlebitis □Clotting/ Bleeding Problems □Enlarged veins in legs □Leg cramps walking or at night □Blurry Vision □Hearing Loss □Ringing in Ears OTHER: URINARY □Blood in Urine □Kidney Stones □ Kidney Dialysis SKIN □Rash □Psoriasis □MRSA GASTROINTESTINAL\ DIGESTIVE □REFLUX □Peptic Ulcer □Hepatitis □Liver Disease □Stomach Problems PSYCHIATRIC □Anxiety □Depression GENERAL □Cancer _________________ □Redness/Heat of any joint? _________________ □Chills □HIV/AIDS □ HISTORY OF GOUT __________________