Patient History HiddenDate MM slash DD slash YYYY Name* First Last Gender Male Female Date of Birth* MM slash DD slash YYYY Primary Care Physician (PCP) First & Last NamePhone number Referring Physician (if not PCP) First & Last NamePhone number Pre-surgical evaluation? Yes No Chief Complaint (reason for consultation) Short of breath Cough Chest discomfort Asthma / wheezing Abnormal x-ray Sinus symptoms Awaken gasping Daytime sleepiness Hard to fall/stay asleep Snoring Restless legs Sleep walking Other Other chief complaint(s) not listed above YOUR MEDICAL HISTORYcheck all that apply Anemia Gallbladder problem Parkinson’s Anxiety Glaucoma Pneumonia Arthritis Head injury Reflux Asthma / Bronchitis Heart disease Restless legs Blood clot: leg Hepatitis Rheumatic fever Blood clot: lung High blood pressure Sarcoidosis Cancer High cholesterol Sinusitis COPD HIV Sleep apnea Covid-19 Insomnia Stroke Depression Intestinal problem TB Diabetes Kidney / Bladder Thyroid Environmental allergies Lupus Ulcer Fibromyalgia Narcolepsy Venereal Disease Type(s) of cancerlunglivergynbrainbreastGIotherOther type(s) of cancer not listed above Type(s) of heart diseaseheart attackatrial fibrillationcongestive heart failuremitral valve prolapseother valve disorderpacemakerinternal defibrillatorotherOther type(s) of heart disease not listed above ThyroidhighlowOther medical problems not listed above SYMPTOMS YOU HAVE HAD IN LAST TWO WEEKScheck all that apply Constitutional Change in weight Fever/chills/night sweats Respiratory Short of breath Coughing/wheezing Coughing up blood Cardiac Chest pain/discomfort Short of breath w/reclining Fast pulse Irregular heartbeat Palpitations Wake up short of breath Black out spells Fainting / dizziness Leg/ankle swelling Eyes, Ears, Hearing difficulty Ringing in ears Nose & Throat Sinus/nasal/cold symptoms Sore throat/hoarseness Changes in vision Throat pain Double vision Gastrointestinal Nausea / vomiting Vomiting blood Trouble swallowing Indigestion or heartburn Abdominal pain/swelling Bloody or dark tarry stools Diarrhea / constipation Genitourinary Problems voiding Problems urinating Sleep Insomnia Trouble falling asleep Snoring Stop breathing in sleep Excessive sleepiness Musculoskeletal Arthritis / joint swelling / aches Joint stiffness Back / rib cage pain Chest wall pain Paralysis / limb weakness Neurological Freq./severe headaches Numbness or tingling Uncoordination / recent falling Weakness in legs/arms Skin Itching / rash Skin lesions Changes in a mole Breast pain/lump/problem Endocrine Heat/cold intolerance Excessive thirst/urination Hematological History of blood clot Enlarged lymph nodes Excessive bruising/bleeding Psychiatric Unusual anxiety Depression Drug/alcohol addiction Other symptoms not listed above SOCIAL HISTORYEmploymentPlease select…working full-timeworking part-timeretireddisabledstudentnone of aboveOccupation Highest Educational Level grade school high school college masters doctorate Smoking History never current former Year in which you quit smoking Cigars/day Cigarette packs/day Years smoked Do you drink alcohol? No Yes Amount Frequency Daily Weekly Caffeinated beverage intake None Tea Coffee Soft drink Amount daily Have you traveled outside of the United States in the last 6 months? No Yes To: FAMILY HISTORY (check all that apply)Click in each of the 4 boxes below to choose any conditions that are applicable for that relative. MotherHeart DiseaseCancerStrokeHigh BPDiabetesSleep DisorderDeceasedFatherHeart DiseaseCancerStrokeHigh BPDiabetesSleep DisorderDeceasedSiblingHeart DiseaseCancerStrokeHigh BPDiabetesSleep DisorderDeceasedGrandparentHeart DiseaseCancerStrokeHigh BPDiabetesSleep DisorderDeceasedOther diseases that run in your immediate family SURGICAL HISTORYList surgeries and approximate dates (at least the year)Use the + icon to add new rows.ProcedureDate IMMUNIZATIONS (include dates if known)Immunizations Flu Pneumonia Covid-19 Hepatitis A/B Meningitis Shingles Tetanus Which Covid vaccine?Please select…PfizerModernaJ&JDate(s) of Covid shot(s)1234Date of flu shot Date of pneumonia shot Date of hepatitis shot Date of meningitis shot Date of shingles shot Date of tetanus shot Have you ever had a positive PPD (TB) skin test? No Yes When was the positive PPD (TB) skin test? KNOWN MEDICATION ALLERGIES & REACTIONSmedication allergiesUse the + icon to add new rows.AllergyWhat happens? PHARMACY INFORMATIONPharmacy Name Pharmacy Phone # Pharmacy Address MEDICATIONS CURRENTLY TAKINGCurrent medicationsUse the + icon to add new rows.medication namedose (mg)take how oftenreason Signature*Type your signature here