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PHYSICAL HISTORY FORM
NAME: _______________________________ Age: ______ Sex: Male_____Female____ Martial Status: (Please check one) Married ___ Divorced___ Single___ Widow___ Please answer the following questions as accurately as possible: 1. Is there any history of diabetes? __________If yes, how long have you been a diabetic? _______ Do you have to take Insulin for diabetes or is it controlled with pills and diet? ______________________________________________________ 2. Is there any history of hypertension (high blood pressure)? _________________ If yes, how long have you had high blood pressure and does your blood pressure remain in good control or not? ___________________________________________ Is there any family history of high blood pressure? ___________________________ Is there excessive salt in your diet? ________________________________________ 3. Is there any history of hemateria (blood in urine)? ____________________________ 4. Is there any history of pain while passing urine? ______________________________ 5. Is there any history of difficulty getting urine stream started or stopping? _________ 6. Is there any history of leakage of urine? _____________________________________ 7. Do you have to wake up during the night to urinate? ____ If so, how many times during the night? ______________________________________________ 8. Is there history of urgency to urinate? _______________ 9. Is there any history of swelling of the face or feet? _______If so, how long has there been swelling of the face or feet? ___________________________________ 10. Do you have a history of kidney stones? ________ If yes, when was your first attack? ____________________ When was your last attack? ____________________ Which side was the attack on? Left _____ Right______ 11. Have you taken any pain medications in the NSAID group (Aspirin, Naprosyn, Motrin, Aleve, Ibuprofen, Nuprin, Celebrex, Vioxx, etc.) __________________________ If so, how long have you been taken NSAIDS? _______________________________ 12. Are you on a water pill? ________How long have you been taking it? ___________ What is the dose of the water pill? ____________________________________ 13. Are you taking Vasotec, Capoten, Zestril, Cozaar, Hyzaar, Diovan or Avapro? ___________________________________________________________________ If yes, how long have you been taking the medicine? ________________________ 14. Is there any family history of renal disease? ________ If yes, whom? ____________ 15. Is there a previous kidney work-up available? ______________________________ CONSTITIONAL:
1. Fever? _________ 2. Body aches? _________ 3. Malaise? _________ 4. Excessive Sweating? ________ CARDIAC:
1. Is there any history of chest pain or previous chest pain? ___________________
2. Is there any history of shortness of breath? ______________________________
Do you sometimes wake up at night with shortness of breath or chest pain? _________________________________________________________________ 3. Is there any shortness of breath on exertion, particularly with climbing? _________________________________________________________________ 4. Is there any history of weakness? ______________________________________ 5. Is there any previous of MI (heart attack)? __________ If yes, when? __________ 6. Is there any history of cardiac arrhythmia (heart beating too fast or too slow)? __________________________________________________________________ 7. Is there any history of CHF (congestive heart failure)? _______________________ 8. Do you see a regular cardiologist? _________ If yes, what is the Cardiologist name? ___________________________________________________________________ PULMONARY:
1. Is there any history of COPD, asthma, bronchitis, or black lung? ______________________________________________________________ 1. Is there any history of nausea, vomiting, diarrhea, constipation, ulcer, diverticulosis, or gallstones? _________________________________________ 2. Is there any history of abdominal surgery? ______ If yes, for what and when was it? ______________________________________________________________ 1. Is there any history of previous stroke or mini-stroke? ______ If yes, when? ________________________________________________________________ 2. Is there any history of seizures? ______________________________________ 3. Is there any history of syncopal episodes (passing out)? ___________________
MUSCULOSKELETAL:
1. Do you have any history of arthritis, gout, joint pain, musculoskeletal, pain, or back pain? ______________________________________________________ What medicines are you taking for this? ______________________________ 2. Is there any history of joint surgery? _________ If yes, when and why? _______________________________________________________________ 1. Do you have a history of eye disease, particularly related to diabetes? ________ 2. Is there any history of cataract operation? _______________________________ EARS/NOSE:
1. Is there any history of ear problems: earache, discharge from the ears, loss of hearing? __________________________________________________________ 2. Is there any history if nasal discharge, sinusitis? ___________________________ 3. Is there any history of ulcers in the mouth? ______________________________ ALLERGIES:
1. Is there any history of allergies (seasonal or medication)? ___________________ _________________________________________________________________ ENDOCRINE:
1. Is there any history of thyroid disease? 2. Do you have a good appetite or a poor appetite? HEMATOLOGY/ONCOLOGY:
1. Is there a history of anemia? __________________________________________ 2. Is there a history of excessive bleeding? _________________________________ 3. Is there any history of cancer? _________________________________________ OB/GYN (FOR FEMALE PATIENTS ONLY):
1. Are you pregnant at this time? __________ If yes, date of delivery? __________ 2. Do you have regular menstrual periods? ________________________________ 3. How many times have you been pregnant? ______________________________ 4. Is there any history of miscarriage, abortion, etc? _________________________ If yes, when? _____________________________________________________ FOR MALES PATIENTS ONLY:
1. Is there any history of prostate disease or problems? ______________________ PAST SURGICAL HISTORY:
1. Is there any history of past surgery? _____ If yes please list below with dates: SOCIAL INFORMATION:
1. Do you live by yourself? _____ If not, with whom do you live? _______________ 2. Do you have any children? _____ If yes, how many? _________ Do they have any medical problems? If yes, what? _______________________ 3. Are your parents living or deceased? Mother _______________ If deceased, cause of death? Mother _______________ 4. Does anyone in your family have chronic kidney disease that you know of? ____ If yes, who? ______________________________________________________ 5. Do you drink alcohol? ________ If yes, how much do you drink a week? ________________________________________________________________ Have you quit smoking? ________________ If so, when? _________________ Before you quit smoking, how much did you smoke? _____________________ Is there anything that you would like to discuss with the doctor that has not already been covered? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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