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    jmfleck
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    The document is a health history form asking the patient to provide information about medical conditions, symptoms, hospitalizations and surgeries, current medications, areas of pain, pain level, and whether experiencing any unexplained symptoms like cough, sweats, fever or weight loss. It requests the patient's name, date, and indicates they should note any previous diagnosis or treatment for various conditions and experiences like heart, lung, cancer, infection issues and tobacco/alcohol use.

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    The document is a health history form asking the patient to provide information about medical conditions, symptoms, hospitalizations and surgeries, current medications, areas of pain, pain level, and whether experiencing any unexplained symptoms like cough, sweats, fever or weight loss. It requests the patient's name, date, and indicates they should note any previous diagnosis or treatment for various conditions and experiences like heart, lung, cancer, infection issues and tobacco/alcohol use.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    56 views1 page

    History

    Uploaded by

    jmfleck
    The document is a health history form asking the patient to provide information about medical conditions, symptoms, hospitalizations and surgeries, current medications, areas of pain, pain level, and whether experiencing any unexplained symptoms like cough, sweats, fever or weight loss. It requests the patient's name, date, and indicates they should note any previous diagnosis or treatment for various conditions and experiences like heart, lung, cancer, infection issues and tobacco/alcohol use.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    Download as pdf or txt
    of 1

    Name: _________________________________________________________

    Date: ______________________

    Health History:
    Please indicate if you have ever been diagnosed with, treated for, or experienced symptoms of any of the following conditions:

    Comments:
    Kidney Disease___________________________
    Angina/Chest Pain_________________________
    Heart Attack/Heart Disease__________________
    High/Low Blood Pressure___________________
    Diabetes_________________________________
    Shortness of Breath________________________
    Asthma/Emphysema_______________________
    Dizziness/Syncope_________________________
    Seizures_________________________________
    Bowel/Bladder Problems____________________
    Rectal/Vaginal bleeding____________________
    Osteoporosis_____________________________

    Comments:
    Cancer_________________________________
    Rheumatic Fever_________________________
    Tuberculosis/TB_________________________
    Hepatitis________________________________
    Stroke/TIA______________________________
    Arthritis________________________________
    Circulation Problems/Phlebitis______________
    Muscle/Nerve Disorder____________________
    Use Tobacco____________________________
    (smoking/chewing)
    Use Alcohol_____________________________
    Are you pregnant? ________________________

    Are you experiencing any of the following?


    __ Unexplained cough of 2 weeks or more
    __ Night Sweats
    __ Unexplained fever
    __ Unexplained weight loss
    __ Loss of appetite
    __ Bloody sputum
    Please list any recent hospitalizations and/or surgeries along with approximate dates:

    Please list the medications that you currently are taking:

    Pain Log: Please shade areas that you are experiencing


    pain and/or altered sensation. Is this pain and/or altered
    sensation continual?
    Yes________
    No________

    Pain Rating: Please circle one of the following


    which best describes your pain today:
    0

    - No pain at all
    - Very, very weak pain
    - Very weak pain
    Weak pain
    3 Moderate pain
    4 Somewhat strong pain
    5 Strong pain
    6
    7 Very strong pain
    8
    9
    10 Very, very strong pain
    10+ - Maximal pain
    .5
    1
    2

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