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PRINT THIS FORM AND BRING THE COMPLETED FORM TO YOUR FIRST OFFICE VISIT.

This questionnaire is designed to assist our office in obtaining a comprehensive medical history.

Name ................................................................................

Gender: male female transgender Age ........................... Date of Birth ...............................

Race:  White   Asian    African-American Ethnicity:    Hispanic      non-Hispanic

Preferred language: English  Spanish  Cambodian   Vietnamese   Laotian  other:

Past Medical History
List all current and past medical problems. None

List all operations, approximate year of surgery and the reason for any hospitalization None

List all the medicines that you take regularly (eg. vitamins, birth control pills, aspirin.) None

Have you ever had an allergic reaction to any medicine? No Yes

Have you ever smoked a pipe, cigars or cigarettes? No Yes

Have you ever drunk more than 10 glasses of alcohol per week on a regular basis? No Yes

Have you ever been exposed to tuberculosis, hepatitis or toxic chemicals? No Yes

Have you ever used intravenous drugs, "shot-up" drugs or are you currently using drugs? No Yes

Family and Social History
Circle as many as apply: single involved married separated divorced widowed

Have you ever had a sexual relationship with someone of the same sex? No Yes

Have you ever been sexually abused? No Yes

Are you in fear of your safety, of being injured or have you been punched or kicked? No Yes

Circle those problems that have affected your mother, father, brothers, sisters or children:
high blood pressure, diabetes, thyroid problems, stroke, tuberculosis, breast cancer,
heart attack, angina, heart failure, colon cancer, high cholesterol, thin bones, ovarian cancer None

If you have children, what are their ages?............................................................................ None

What was the highest grade level that you completed in school?.....................................................

What is your occupation?.......................................................................................................

Do you wear your seat belt? Never sometimes usually always

Circle All of the Following Problems That Have Affected You

My overall state of health is: excellent very good good fair poor

Height: .......................... Weight: ...........................

General: weight gain, weight loss, weakness, fatigue, AIDS, fever, night sweats, cancer None

Skin: rashes, skin lumps, skin cancer, a change in the appearance of a rash, severe acne None

Head, Eyes, Ears, Nose & Throat: headaches, a history of a head injury, earaches,
difficulty smelling, cataracts, glaucoma, sinus trouble, nose bleeds, ringing in the ears,
difficulty hearing, hoarse voice, vision problems, lumps in the neck, swollen glands None

Lungs: cough, coughing up blood or sputum, asthma, bronchitis, emphysema None

Heart: Do you take antibiotics before dental work?.............................................................. No Yes
chest pain, chest pressure or tightness, heart attack, high blood pressure, swollen ankles, angina,
heart murmur, waking at night short of breath, high cholesterol, heart failure, irregular heartbeats
shortness of breath during exercise, palpitations, rheumatic fever, leg pains when walking None

Gastrointestinal: vomiting, black stools, blood in your stools, ulcers, heartburn, hernia,
diarrhea, gallstones, yellow skin, pancreatitis, hemorrhoids, constipation, stomach pains None

Urinary-Reproductive: Do you or your sexual partner use some form of contraception? Yes No
blood in urine, VD, gonorrhea, syphilis, AIDS, wake at night to urinate, kidney stone,
bladder infections, urinate frequently, burning when you urinate, a loss of sexual desires None

Men only: a discharge from your penis, difficulty urinating, difficulty with erections,
a sore on your penis, an episode of a testicle infection, vasectomy, a lump in your testicles None

Women only: Do you use birth control pills?...................................................................... No Yes
irregular periods, periods have stopped, bleeding between your periods, extra hair growth, breast discharge, breast lumps, tubal ligation, hysterectomy, vaginal discharge, P.I.D, abnormal mammogram or Pap smears, post-menopausal bleeding, hot flashes None

Muscle-Skeletal: joint pains, muscle pains, bursitis, rheumatoid arthritis, "lupus,"
degenerative joint disease, arthritis, gout, back pain, osteoporosis, "thin bones" None

Endocrine: thyroid problems, sweat easily, always feel hot, inability to fall asleep, a "goiter," radiation to face or neck, always feel cold, excessive sleepiness, increased or decreased appetite None

Diabetics only: When did you last see an eye doctor?............................. Unknown
Do you see a podiatrist (foot doctor) on a regular basis?........................... No Yes
sores on your feet, diabetic kidney disease, diabetic eye disease, frequent low blood sugars, "laser" eye surgery, pain in your toes or feet, abnormal feeling in your toes or feet, None

Neurologic: fainting, blackouts, seizures, strokes, tremor, dizziness, epilepsy None

Blood: anemia, easy bruising, frequent colds or infections, blood clots, "phlebitis" None

Psychiatric: depression, hearing voices, anxiety, "nerve problems," thoughts of suicide None

Is there anything else you want to tell Dr. Ariza or Dr. Zwerling? No Yes