Please complete the following form and bring with you on the day of your physical.

Patient's Personal History Patient No.
E-mail address: Date
Last Name First Middle
Address City State Zip
Birth Date Birth Place Home Phone Business Phone
Occupation Medicare No. Medicaid No. Sex
Male
Female
Insurance Company Insurance Number Marital Status Religion
Emergency contact person: Relationship:
Address: Phone Number:
Date of Last Physical Examination: Doctor:
Family or Referring Physician: Address:
Family History If Living If Deceased
  Sex

M - F

 Age Health Age at Death Cause
Father X  
Mother   X
Brothers/Sisters
Husband/Wife
Sons/Daughters

Please indicate a response of yes by giving relationship to person in space provided.

Stroke Epilepsy Heart Attack Nervous Breakdown
Cancer Suicide Stomach Ulcers Rheumatic Heart
High Blood Pressure Migraine Kidney Disease Insanity
Tuberculosis Asthma Goiter Congenital Heart
Diabetes Hay Fever Arthritis  
Leukemia Bleeding Tendency Colitis  

Personal Habits: Check all that apply.

Yes No Do you regularly smoke? Cigarettes Pipe Cigars
For how many years?
Yes No Do you usually drink over 6 cups of coffee per day?
Yes No Do you regularly drink alcohol? 1 Oz. per day 2 Oz. per day
4 Oz. per day Over 6 Oz. per day
Beer: 1 bottle per day 2 bottles per day Over 4 bottles per day
Yes No Do you have difficulty falling asleep?
Yes No Do you awaken early in the morning without apparent cause?

Medications:

Are you presently taking any of the following medications? (check all that apply)

Yes No Aspirin, bufferin, anacin Yes No Tranquilizers
Yes No Blood pressure pills Yes No Weight reducing pills
Yes No Cortisone Yes No Blood thinning pills
Yes No Cough medicine Yes No Dilantin
Yes No Digitalis Yes No Shots
Yes No Hormones Yes No Water pills
Yes No Insulin or diabetic pills Yes No Antibiotics
Yes No Iron or poor blood medications Yes No Barbituates
Yes No Laxatives Yes No Birth control pills
Yes No Sleeping pills Yes No Phenobarbital
Yes No Thyroid medicine Yes No Other drugs not listed

Write in the names and year of any operations which you have had:

Name any drugs to which you are allergic:

Write in the names of any diseases you have had which required hospitalization:

Serious Illnesses which you have had (not requiring hospitalization):

Serious injuries or accidents:

To be answered by WOMEN only:

Yes No Are you still having regular monthly menstrual periods?  
Yes No Have you ever had any bleeding between your periods? When?
Yes No Do you have very heavy bleeding with your periods? When?
Yes No Do you feel very bloated and irritable before your period?  
Yes No Are you now on or have you ever taken the birth control pill? When?
Yes No Have you ever had a miscarriage? When?
Yes No Have you ever had a discharge from the nipple of your breast? When?
Yes No Do you regularly have the cancer test of the cervix? Date of last test:

How many miscarriages?

How many children born alive? How many miscarriages?
How many stillbirths? How many cesarean operations?
How many premature births? Any complication of pregnancy?
Date of last menstrual cycle?  

To be answered by men and women:

Yes No Do you frequently have severe headaches? (If yes, answer the following):
Yes No Do they cause visual trouble?
Yes No Do they occur on one side of the head?
Yes No Do they awaken you at night from sleep?
Yes No Do they feel like a tight hat band?
Yes No Do they hurt most in the back of the head and neck?
Yes No Does aspirin relieve them?
Yes
No		 Have you ever fainted? Yes
No		 Have you ever had a convulsion?
Yes
No		 Spells of dizziness? Yes
No		 Double vision?
Yes
No		 Spells of weakness in an arm or leg? Yes
No		 Pains in ear?
Yes
No		 Ringing in ears? Yes
No		 Nosebleeds?
Yes
No		 Do you frequently have bleeding gums? Yes
No		 Do you frequently have a sore tongue?
Yes
No		 Do you frequently have trouble swallowing? Yes
No		 Do you frequently have nausea and vomiting?
Yes
No		 Do you frequently have hoarseness?    

Have you ever had shortness of breath?

Yes
No		 Doing your usual work? Yes
No		 Which causes you to cough?
Yes
No		 Climbing a flight of stairs? Yes
No		 Accompanied by wheezing?
Yes
No		 Which awakens you at night? Yes
No		 Have you ever coughed up blood?
Yes
No		 Do you have a chronic cough? Yes
No		 Do you cough up much sputum?

Have you ever had chest pain or tightness in the chest which begins when:

Yes
No		 When exerting yourself? Yes
No		 Radiates down the arm?
Yes
No		 When walking against a wind? Yes
No		 Disappears if you rest?
Yes
No		 When walking up a hill? Yes
No		 Occurs only at rest?
Yes
No		 After a heavy meal? Yes
No		 When walking fast?
Yes
No		 When upset or excited? Yes
No		 When walking in cold weather?
Yes
No		 Palpitations Yes
No		 Do you sleep on more than one pillow?

If you have chest pain or tightness please explain:

Have you recently had pain in the stomach which:

Yes No Occurs 1 - 2 hours after a meal?
Yes No Is brought on by eating fried foods, gassy foods?
Yes No Awakens you at night?
Yes No Is relieved by antacid medications?
Yes No Is relieved with milk or eating?
Yes No Occurs while eating or immediately after?
Yes No Is relieved by a bowel movement?
Yes No Loss of appetite?
Have you had: When or since when?
Yes No Burning when urinating?
Yes No Loss of control of bladder?
Yes No Blood in the urine?
Yes No Dark colored urine?
Yes No Trouble starting to urinate?
Yes No Trouble holding the urine?
Yes No Getting up frequently at night?
Yes No Passed a kidney stone?
If you have had a change in bowel habit recently answer the following: When or since when?
Yes No Crampy pain in the abdomen?
Yes No Alternating diarrhea and constipation?
Yes No Pain during or after bowel movement?
Yes No Mucous in the stool?
Yes No Blood in the stool?
Yes No Ribbon-like stools?
Yes No Black stools?
Yes No Require use of strong laxatives or enemas?
Have you recently had: When or since when?
Yes No Pains in calves of legs when walking?
Yes No Cramps in legs at night?
Yes No Pain in the big toe?
Yes No Varicose veins?
Yes No Phlebitis or inflamed leg veins?
Yes No Swelling in the ankles?

To be answered by MEN only: Have you ever had:

Yes No Loss of sexual activity? For how long?
Yes No Treatment for the genitals (private parts)?
Yes No Discharge from the penis?
Yes No Hernia (rupture)?
Yes No Prostate trouble?

Describe briefly your present medical symptoms:

Please indicate any immunizations you have had:

TB Skin Test Date:
Tetanus Toxoid Date:
Tetanus Diptheria Date:
Pertussis Date:
Pneumonia Vaccine Date:
Flu Vaccine Date:
Hepatitis B Date:
Measles Date:
Mumps Date:
Rubella Date:
Polio Date:
Cholera Date:
Typhoid Date:
Other: Date:
Other: Date:
Other: Date: