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Complete Medical History Questionnaire



General: Weight change, weakness, fatigue, fever, chills, night sweats, history of cancer, average number of hours’ sleep/night____.

Skin: Rashes, dryness, lesions, skin, hair or nail changes, excessive sweating, itching, lumps, bleeding, bruising, piercings, tattoos. Use of sunscreen use, tanning beds. Changes in in size or color of moles, non-healing wounds.

Head, Eyes, Ears, Nose, Throat (HEENT):

Head: Headache, head injury, dizziness, lightheadedness.

Eyes: Vision, visual changes, use of glasses, contact lenses, prosthetics.  Pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights cataracts, glaucoma. Last comprehensive eye exam _____.

Ears: Hearing loss, tinnitus, vertigo, earaches, infection, discharge, ruptured tympanic membrane, occupational exposure to loud noise, use of hearing aids, use of ear buds or headphones.

Nose and sinuses: Nasal congestion/stuffiness, sinus pain, discharge or itching, frequent colds/URIs, chronic sinus infections, epistaxis, olfactory changes or loss of smell, deviated septum, allergic rhinitis.

Throat (mouth and pharynx): Condition of teeth and gums (caries, tooth pain, extractions, dentures, caps, loose teeth, gum disease, bleeding gums) bad breath, taste changes, sore throat, hoarseness, sore tongue, dry mouth, difficulty chewing, lesions of lips or oral mucosa, frequency of brushing/ flossing_____, date of last dental exam_____.
Neck: Swollen glands, goiter, lumps, pain, neck stiffness.

Breasts: Skin changes, pain or discomfort, nipple changes, lumps (masses), discharge. Female: fibrocystic disease, breast cancer history, knowledge and frequency of self-exam, date of last mammogram______.

RESPIRATORY: Cough, sputum (color and quality), snoring, wheezing, shortness of breath/dyspnea, pain with deep breath (pleuritic pain), hemoptysis, frequent respiratory infections, asthma, bronchitis, emphysema/COPD. History of pneumonia, tuberculosis, last tuberculin test and result_________. Last CXR or Chest CT______.

Cardiovascular: Heart disease, high blood pressure, chest pain, angina pectoris, palpitations, exertional dyspnea, orthopnea, murmurs, rheumatic fever, swelling of lower extremities or hands.                     Past EKG or other cardiac testing, (stress test, echocardiogram) date/s_________.

Gastrointestinal: Abdominal pain, dysphagia, appetite changes, heart burn/pyrosis, food intolerance, nausea, vomiting, hematemesis, eating disorders, excessive belching or flatus, change in bowel habits, diarrhea, constipation, hemorrhoids, melena, mucous in stool, hernia, liver or gallbladder disease (hepatitis, jaundice, stones), pancreatitis, use of laxatives or antacids. Frequency of bowel movements____.

Peripheral vascular: Claudication, leg cramps, varicose veins, swelling and/or redness of legs, calves, ankles or feet, color changes of lower extremities, color changes in fingertips and toes in cold temperatures. History of DVT.

Urinary: Dysuria, frequency, urgency, hesitancy, nocturia, polyuria,

incontinence, decreased urinary stream, urinary infections, calculi. Male: enlarged prostate or prostate cancer.

Genital: Male: Hernias, discharge from penis or sores, testicular pain or masses, scrotal pain or swelling, history of STIs and their treatments. Sexual habits, interest function, satisfaction, birth control methods, condom use, any problems. Concerns about HIV infection.

Genital: Female: Age at menarche, regularity, frequency and duration of periods, amount of bleeding; bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Last menstrual period (LMP)______.        

Age at menopause, menopausal symptoms, postmenopausal bleeding, exposure to DES (if born prior to 1971). Vaginal discharge, itching, sores, lumps, STIs and treatments. Number of pregnancies, number and type of deliveries, number of abortions/miscarriages, complications of pregnancy, birth control methods. Sexual habits, interest function, satisfaction, birth control methods, any problems, dyspareunia. Concerns about HIV infection.

Musculoskeletal: Muscle (myalgias) or joint pain, stiffness, weakness, arthritis, gout, neck pain, backache, swelling and/or redness of joints, joint deformities, bone fractures, neuropathy, sciatica.

Psychiatric: Nervousness, tension, mood, anxiety, depression, hyperventilation, insomnia, phobias, memory changes, nightmares, suicidal ideation, suicide plans or attempts. Past counseling, psychotherapy or psychiatric admissions.

Neurologic: Changes in mood, attention, or speech, changes in orientation, memory, insight or judgment, headache, dizziness, vertigo, fainting, blackouts, weakness, paralysis, numbness or loss of sensation, paresthesia, tremors, other involuntary or abnormal movements, seizures, altered gait. Use of assistive devices for mobility. History of falls.
Hematologic: Anemia, easy bruising or bleeding, clotting disorders, lymphadenopathy, neutropenia, thrombocytopenia, polycythemia. History of blood transfusions, iron infusions, blood disorders or leukemia.

Endocrine: Diabetes, thyroid disease, parathyroid disorders, goiter, heat or cold intolerance, excessive sweating, polyuria, polyphagia, polydipsia, hirsutism (female), gynecomastia (male).

Value/beliefs: Impact of religious beliefs on health care practices. Advanced directives, general health care practices, use of complementary health care practices. 

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