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? ______________________________
1. Fever? _________ 2. Body aches? _________ 3. Malaise? _________ 4. Excessive Sweating? ________
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?
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
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)? ___________________
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? _______________________________
1. Is there any history of ear problems: earache, discharge from the ears, loss of
2. Is there any history if nasal discharge, sinusitis? ___________________________
3. Is there any history of ulcers in the mouth? ______________________________
1. Is there any history of allergies (seasonal or medication)? ___________________
1. Is there any history of thyroid disease?
2. Do you have a good appetite or a poor appetite?
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:
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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