"Medical History and Review of Systems Form - Northeast Georgia Physicians Group"

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HISTORY AND
REVIEW OF SYSTEMS
FRONT
Name: _____________________________________________________ DOB: _____ / _____ / _____ Today’s Date: _________________
Primary Care Physician: _______________________________________ Referring Physician: ___________________________________
What are we seeing you for today? ___________________________________________________________________________________
How long have you had this problem? ____________________ Telephone or location of your pharmacy: ___________________________
CURRENT MEDICAL HISTORY: Please check (3) all that apply:
o Abnormal Heart Rhythm
o COPD
o Heart Attack
o Pneumonia
o Anemia
o Colon Polyps
o Hiatal Hernia/GERD
o Stomach Ulcers
o Aneurysm
o Congestive Heart Failure
o High Cholesterol
o Stroke
o Arthritis
o Coronary Artery Disease
o High/Low Blood Pressure
o TIA
o Asthma
o Depression
o Implanted Device
o Thyroid Disease
o Cancer:
_____________
o Diabetes: o Type I o Type II
o Kidney Disease/Stones
o Tuberculosis
type
o Carotid Artery Disease
o Emphysema
o Liver Disease
o Ulcers
o Cirrhosis of the Liver
o Epilepsy
o Low Blood Sugar
ALLERGIES: List all medication and/or food allergies and the type of reaction (Ex: Sulfa-rash, Codeine-nausea, etc.)
Allergy:
Type of reaction:
1. ______________________________________________________
_____________________________________________________
2. ______________________________________________________
_____________________________________________________
3. ______________________________________________________
_____________________________________________________
4. ______________________________________________________
_____________________________________________________
5. ______________________________________________________
_____________________________________________________
Are you allergic to latex? o Yes o No
Circle any of the following that you are currently taking on a regular basis:
Aspirin
Arthritis medication
Xarelto
Eloquis
Coumadin/Warfarin
Other blood thinner
CURRENT MEDICATIONS: List all medications:
Over-the-Counter
Medicine
Dosage
How Often?
Provider
Vitamins and Supplements
EX: Lasix
20 mg
Twice a day
Dr. Jones
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
SURGICAL HISTORY:
Appendectomy – Date: __________________________________
Endoscopy – Date: _____________________________________
Back/Neck – Date: _____________________________________
Gallbladder – Date: _____________________________________
Bariatric – Date: _______________________________________
Hernia Repair – Date: ___________________________________
Breast – Date: _________________________________________
Hysterectomy – Date: ___________________________________
Cardiac – Date: ________________________________________
Reflux – Date: _________________________________________
Colon – Date: _________________________________________
Thyroid – Date: ________________________________________
Colonoscopy – Date: ___________________________________
Other abdominal surgery: – Date: _________________________
NGMC FORM # 506040-02968 (6/18/15)
HISTORY AND
REVIEW OF SYSTEMS
FRONT
Name: _____________________________________________________ DOB: _____ / _____ / _____ Today’s Date: _________________
Primary Care Physician: _______________________________________ Referring Physician: ___________________________________
What are we seeing you for today? ___________________________________________________________________________________
How long have you had this problem? ____________________ Telephone or location of your pharmacy: ___________________________
CURRENT MEDICAL HISTORY: Please check (3) all that apply:
o Abnormal Heart Rhythm
o COPD
o Heart Attack
o Pneumonia
o Anemia
o Colon Polyps
o Hiatal Hernia/GERD
o Stomach Ulcers
o Aneurysm
o Congestive Heart Failure
o High Cholesterol
o Stroke
o Arthritis
o Coronary Artery Disease
o High/Low Blood Pressure
o TIA
o Asthma
o Depression
o Implanted Device
o Thyroid Disease
o Cancer:
_____________
o Diabetes: o Type I o Type II
o Kidney Disease/Stones
o Tuberculosis
type
o Carotid Artery Disease
o Emphysema
o Liver Disease
o Ulcers
o Cirrhosis of the Liver
o Epilepsy
o Low Blood Sugar
ALLERGIES: List all medication and/or food allergies and the type of reaction (Ex: Sulfa-rash, Codeine-nausea, etc.)
Allergy:
Type of reaction:
1. ______________________________________________________
_____________________________________________________
2. ______________________________________________________
_____________________________________________________
3. ______________________________________________________
_____________________________________________________
4. ______________________________________________________
_____________________________________________________
5. ______________________________________________________
_____________________________________________________
Are you allergic to latex? o Yes o No
Circle any of the following that you are currently taking on a regular basis:
Aspirin
Arthritis medication
Xarelto
Eloquis
Coumadin/Warfarin
Other blood thinner
CURRENT MEDICATIONS: List all medications:
Over-the-Counter
Medicine
Dosage
How Often?
Provider
Vitamins and Supplements
EX: Lasix
20 mg
Twice a day
Dr. Jones
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
SURGICAL HISTORY:
Appendectomy – Date: __________________________________
Endoscopy – Date: _____________________________________
Back/Neck – Date: _____________________________________
Gallbladder – Date: _____________________________________
Bariatric – Date: _______________________________________
Hernia Repair – Date: ___________________________________
Breast – Date: _________________________________________
Hysterectomy – Date: ___________________________________
Cardiac – Date: ________________________________________
Reflux – Date: _________________________________________
Colon – Date: _________________________________________
Thyroid – Date: ________________________________________
Colonoscopy – Date: ___________________________________
Other abdominal surgery: – Date: _________________________
NGMC FORM # 506040-02968 (6/18/15)
HISTORY AND
REVIEW OF SYSTEMS
BACK
FAMILY HISTORY: Please check &/or list all family members that apply
Illness:
Relation to you (circle)
Alive
Deceased
Brain Aneurysm
Mother
Father
Sibling
Child
Other
o
o
Cancer
Mother
Father
Sibling
Child
Other
o
o
Diabetes
Mother
Father
Sibling
Child
Other
o
o
Heart Disease
Mother
Father
Sibling
Child
Other
o
o
Hypertension
Mother
Father
Sibling
Child
Other
o
o
Thyroid Problems
Mother
Father
Sibling
Child
Other
o
o
Stroke
Mother
Father
Sibling
Child
Other
o
o
SOCIAL HISTORY: Check &/or list all family members that apply:
Tobacco Use:
o Current / Former (Quit year ________) o Never o Exposure to smoke o E-cigs o Other: __________________
Alcohol Use:
o Never drink o Occasional drinker: _______ # drinks/day of alcohol
Drug Use:
o None o Other use: _____________________________________________________________________________
Caffeine Use:
o No o Yes – how much: __________________________________________________________________________
Marital Status:
o Married
o Divorced
o Widowed
o Single
Spouse’s Name: ________________________________________
# children ____________
# grandchildren ____________
REVIEW OF SYSTEMS: Check all that you are currently experiencing:
General History:
Ear/Nose/Throat:
Neurologic:
Vascular:
o Weight Gain
o Hoarseness
o Muscle Weakness
o Mini-Strokes/TIAs
o Weight Loss
o Choking
o Numbness
o Pain in legs when walking
o Increased Fatigue
o Sore Throat
o Seizures
o Cramping in legs
o Trouble Sleeping
o Ear Aches
o Memory Loss/Dementia
o Increased Appetite
o Sinus Drainage
Gastrointestinal:
Breast (Female):
Hematologic/Lymphatic:
o Heartburn
o Breast Mass
o Slow to Heal After Cuts
o Regurgitation
o Nipple Discharge:
o Easily Bruise or Bleed
o Difficulty Swallowing
If yes, what color? ________________
o Anemia
o Abdominal Pain
o Breast Pain/Tenderness
o Phlebitis
o Nausea
o Changes in Appearance
o Past Transfusion
o Vomiting
o Family History of Breast Cancer
o Enlarged Glands
o Bloating
OB/GYN (Female):
Allergic/Immunologic:
o Early Feeling of Fullness
o Date of Last Period ________________
o History of Skin Reaction To: ___________
o Rectal Bleeding
o Age of Menstruation ________________
o Penicillin or Other Antibiotics
o Constipation
o Menopause
o Morphine or Other Narcotics
o Diarrhea
o Novocaine or Other Anesthetics
Genitourinary:
o Change in Size/Color of stool
o Tetanus or Other Serums
o Difficulty Urinating
o # Bowel Movements/Day: ________
o Iodine or Other Antiseptic
o Urinating Frequently at Night
Respiratory:
o Known Food Allergies _______________
o Blood in Urine
o Difficulty Breathing
o Loss of Bladder Control
o Wheezing
o Weak Stream
o Cough:
o Mucous
o Blood
Endocrine:
Cardiac:
o Glandular or Hormone Problem
o Chest Pains
o Thyroid Disease
o Palpitations
o Excessive Thirst or Urination
o Swollen Feet
o Heat or Cold Intolerance
o Shortness of Breath (when lying flat)
o Cardiac Cath:
If yes, when: __________
o Cardiac Stress Test:
If yes, when: __________
NGMC FORM # 506040-02968 (6/18/15)
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