POLYCLINIC

PLEASE PRINT THIS INFORMATION BECOMES PART OF YOUR CONFIDENTIAL MEDICAL RECORD. PLEASE PRINT
NAME
Type of Work _______________________________________

LAST FIRST MIDDLE INITIAL Marital/Partner Status ________________________________

How would you like to be addressed by our staff (i.e., Mr./Ms.
or first name)? _________________________________________
ADDRESS ____________________________________________
_____________________________________________________
PHONE(s) ____________________________________________
PAST HISTORY (GIVE NAMES AND DATES)
Education (years completed)
GRADE________ HIGH ________ VOCATIONAL ________ COLLEGE ______
Previous Primary Care Physician _______________________
Other treating physician(s) ____________________________
Last eye exam______________ Last dental exam __________
Last tetanus shot ____________________________________

PREVIOUS SURGERY

PREVIOUS
HOSPITALIZATIONS
MAJOR ILLNESS
OR
INJURY

AGE IF AGE AT PRESENT CONDITION OR CHECK IF ANY

FAMILY HISTORY LIVING DEATH CAUSE OF DEATH RELATIVES HAVE HAD:

FATHER DIABETES ........................................................ 

MOTHER HEART TROUBLE ............................................ 
HEART ATTACK ............................................... 
BROTHERS: HIGH BLOOD PRESSURE .............................. 
NUMBER:________ STROKE ........................................................... 
CANCER .......................................................... 
TUBERCULOSIS.............................................. 
SISTERS:
MELANOMA ..................................................... 
NUMBER:________
ARTHRITIS ....................................................... 
OBESITY (OVERWEIGHT) .............................. 
SUICIDE ........................................................... 
CHILDREN: MENTAL ILLNESS............................................ 
NUMBER:________ THYROID TROUBLE ........................................ 
______________________________________

NUMBER LIVING IN YOUR HOUSEHOLD _______________

SMOKING: ALCOHOL: CAFFEINE WEAR HELMET SMOKE ANY RISK FACTORS
WHEN BIKING? ALARMS? FOR HEPATITIS OR AIDS
PACKS PER DAY___________ PER DAY _________ (coffee, tea, cola): (SUCH AS BLOOD TRANSFUSIONS,
 YES  NO  YES  NO
NO. YEARS _______________ PER WEEK _______ CUPS PER DAY ______ SEXUAL CONTACTS, IV DRUG USE)?

YEAR STOPPED ___________ ALCOHOL PROBLEM ASPIRIN USE CAR SEAT BELTS?  YES  NO

 PIPE  CIGAR  CHEW  YES  NO TABS PER DAY __________  YES  NO  LET’S DISCUSS

WEIGHT: CURRENT________ 1 YEAR AGO ________ GOAL: ________ HEIGHT:_________

DRUGS FREQUENTLY Prescription Drugs Over the counter Drugs and Supplments Herbal
OR PRESENTLY USED

SPECIFY ANY DRUG REACTION OR ALLERGY: ________________________________________________________________________________

5000990713
#5000990911
SYSTEM REVIEW: CHECK IF YOU HAVE HAD ANY OF THE FOLLOWING SYMPTOMS OR FINDINGS TO AN UNUSUAL
OR SIGNIFICANT DEGREE:

HEADACHE ...........................  TROUBLE HEART TROUBLE .................  DIABETES ............................. 

SWALLOWING .................. 
FAINTING ..............................  HEART MURMUR .................  HYPOGLYCEMIA .................. 
LOSS OF APPETITE ............. 
DIZZINESS ............................  RHEUMATIC FEVER .............  THYROID TROUBLE ............. 
INDIGESTION ....................... 
SEIZURE ...............................  PALPITATION ........................  G0ITER .................................. 
HEART BURN ....................... 
EAR TROUBLE .....................  IRREGULAR HEART BEAT...  HOT FLASHES ...................... 
NERVOUS STOMACH .......... 
SINUS TROUBLE ..................  TIRE EASILY .........................  FLUID RETENTION .............. 
ULCERS ................................ 
STUFFY NOSE .....................  ANGINA .................................  WEAKNESS .......................... 
VOMITING BLOOD ............... 
NOSE BLEEDS .....................  ENLARGED HEART ..............  NERVOUS ............................. 
PASSING BLOOD ................. 
ALLERGY ..............................  HIGH BLOOD IRRITABLE ............................ 
ABDOMINAL PAIN ................  PRESSURE ....................... 
HOARSENESS ......................  DEPRESSED ........................ 
COLITIS .................................  ANKLE SWELLING ............... 
TIRED .................................... 
DIARRHEA ............................ 
COUGH .................................  TROUBLE SLEEPING ........... 
CONSTIPATION ....................  ARTHRITIS ............................ 
WHEEZING ........................... 
HEMORRHOIDS ...................  BACK PAIN ............................ 
PLEURISY .............................  KIDNEY TROUBLE ............... 
CHANGE IN BOWEL BURSITIS .............................. 
PNEUMONIA .........................  HABITS ..............................  URINE INFECTION ............... 
MUSCLE CRAMPS ................ 
TUBERCULOSIS ...................  GALL BLADDER DIFFICULTY URINATING ...... 
TROUBLE ..........................  NUMBNESS .......................... 
SHORTNESS OF BREATH ...  PROSTATE TROUBLE .......... 
YELLOW JAUNDICE VARICOSE VEINS ................. 
NIGHT SWEATS ....................  (HEPATITIS) .......................  SUGAR IN URINE ................. 
PHLEBITIS ............................ 
CHEST PAIN .........................  LIVER DISEASE ....................  BLOOD IN URINE ................. 
COUGHED UP BLOOD .........  INFERTILITY
INJFERTILITY ....................... 
ABNORMAL ELECTRO-
ASTHMA................................  ANEMIA .................................  CARDIOGRAM (EKG) .......  IMPOTENCE ......................... 

BLOOD DISORDER ..............  ABNORMAL X-RAY ...............  DECREASED LIBIDO ........... 

SKIN TROUBLE ....................  HIGH BLOOD SUGAR ..........  OTHER ................................... 

TUMOR OR SWELLING ........  LOW BLOOD SUGAR ........... 

ACTIVITY (CHECK ONE OR MORE BOXES):

I SEDENTARY LIFE WITH LITTLE EXERCISE ........................  III OCCASIONAL VIGOROUS ACTIVITY WITH
WORK OR RECREATION ..................................................... 
II MILD EXERCISE WITH JOB, HOUSE OR RECREATION
(CLIMB STAIRS, WALK OVER 3 BLOCKS, GOLF, IV REGULAR VIGOROUS EXERCISE PROGRAM
BOWL, ETC.) ..........................................................................  OR HARD WORK.................................................................... 

DATE LAST ANY MENSTRUAL PROBLEMS:  YES  NO

MENSTRUATED?__________
HEAVY PERIODS _________________ IRREGULAR PERIODS_______________
FOR WOMEN ONLY

FOR WOMEN ONLY

PERIOD EVERY _____ DAYS INFREQUENT PERIODS ___________ PAINFUL PERIODS __________________

NUMBER OF NUMBER OF BIRTH CONTROL METHOD DATE OF LAST MAMMOGRAM:________

PREGNANCIES _______ MISCARRIAGES_______ (IF ANY)_______________ PAP SMEAR:______________
CHECK IF YOU  D&C  TOXEMIA  ABNORMAL PAP
HAVE HAD:  HYSTERECOMY  CESAREAN SECTION
 DIFFICULT WITH PREGNANCY  DIFFICULTY WITH LABOR  DIFFICULTY WITH DELIVERY

FORM FILLED OUT BY: ______________________________________________

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PROVIDER: __________________________________DATE:_______________