Medical History Page 2
| fFAMILY HISTORY Please circle all that apply to your family.If yes, which family member? |
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| Yes No | Diabetes | Yes No | Kidney Stones |
| Yes No | Prostate Cancer | Yes No | Abnormal Bleeding |
| Yes No | Heart Attack | Yes No | Tuberculosis |
| Yes No | Cancer | Yes No | Kidney Problems |
| Yes No | High Blood Pressure | Yes No | |
| DO YOU HAVE OR HAVE YOU PREVIOUSLY HAD.... circle all that apply. | |||
| Yes No | Frequent or Severe Headaches | ||
| Yes No | Dizziness | ||
| Yes No | Blurred Vision | ||
| Yes No | Any other Vision Problems | ||
| Yes No | Decrease in Hearing | ||
| Yes No | Recurrent nose bleeds | ||
| Yes No | Chest Pain | ||
| Yes No | Heart Attack | ||
| Yes No | Irregular Heart Beat/Pacemaker | ||
| Yes No | Abnormal Bleeding tendency | ||
| Yes No | Asthma, Emphysema, Bronchitis | ||
| Yes No | Chronic or Frequent Cough | ||
| Yes No | Shortness of Breath | ||
| Yes No | High Blood Pressure | ||
| Yes No | elching or heartburn | ||
| Yes No | Stomach or colon disorders | ||
| Yes No | Nausea/vomiting/Diarrhea | ||
| Yes No | Vomited Blood | ||
| Yes No | Abdominal Cramping | ||
| Yes No | Change in size, shape, or texture of bowel movement | ||
| Yes No | Blood in bowel movement | ||
| Yes No | Backaches | ||
| Yes No | Tiredness or weight loss without apparent reason | ||
| Yes No | Cancer | ||
| Yes No | Any other medical problems not listed above | ||
| WOMEN
ONLY Please circle or answer. |
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| Date of last
period __________Date of last pelvic examination/PAP smear
_________ Any discharge from the vagina Yes No Are you pregnant Yes No How many pregnancies _____ C-Sections ______Vaginal Deliveries ________ Have you ever been diagnosed with endometriosis Yes No |
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| Thank you for supplying us with this important information. Please remember to fill-out these forms and bring them with you for your appointment. | |||