Follow-up visit
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*
) Marked Fields Are Required
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Patient's Name:
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Sex:
*
Age:
M
F
Marital Status:
Single
Married
Widowed
Divorced
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Patient's Social Security :
*
Residence Address:
*
Home Phone:
*
City:
*
State:
*
Zip:
Current Medications
Are you currently taking any prescription and/or non-prescription medications including vitamins,nutritional supplements, oral contraceptives, pain relievers, diuretics, laxatives, allergy medications and cold medications? If yes, list medications below.
Yes
No
If Yes Name of Medication
Dosage (mgs)
How often taken
Update Past Medical History
Have there been any changes in your medical condition since your last visit here?
Yes
No
If yes, describe
Have you seen a physician/healthcare provider since your last visit here?
Yes
No
If yes, please complete the following:
Name
Date Seen
Specialty/Problems
Treatment
Update Family History
Have there been any births, deaths or major illnesses affecting your blood relatives since your last visit here?
Yes
No
If yes, describe
Update Social History
Have there been any changes in your living arrangement, employment or education since your last visit here?
Yes
No
If yes, describe
Substance
Currently use?
Type/Amount/Frequency
How long?
Caffeine
yes
No
Tobacco
yes
No
Alcohol
yes
No
Recreational/Street Drugs
yes
No
Review of Systems
Indicate whether you have experienced the following symptoms during recent weeks. Indicate the symptom(s) when multiple symptoms are listed.
Skin rash, sore excessive bruising
Yes
No
Excessive thirst or urination
Yes
No
Change of a mole
Yes
No
Change in sexual drive or performance
Yes
No
Significant headaches
Yes
No
Diminished hearing, dizziness, hoarseness
Yes
No
Sinus problem, asthma
Yes
No
Cough, shortness of breath, wheezing
Yes
No
Coughing up sputum or blood
Yes
No
Blackouts or loss of conciousness
Yes
No
Chest pain, pressure
Yes
No
Rapid or irregular heart beats
Yes
No
Awakening at night short of breath
Yes
No
Abnormal swelling in legs or feet
Yes
No
Pain in calves when you walk
Yes
No
Difficulty swallowing, heartburn
Yes
No
Nausea, vomiting, diarrhea
Yes
No
Significant problems with constipation
Yes
No
Blood in bowel movements
Yes
No
Difficulty starting urinary stream
Yes
No
Unable to completely empty bladder
Yes
No
Leaking urine
Yes
No
Burning or pain when urinating
Yes
No
Pain, stiffness or swelling in back, muscles
Yes
No
Fever, large lymph nodes
Yes
No
At risk for HIV or AIDS
Yes
No
Weight loss or gain of more than 100 lbs
Yes
No
Experiencing an unusually stressful situation
Yes
No
Problems falling asleep, staying asleep
Yes
No
Sleep apnea, snoring
Yes
No
