Patient History
Dr's. Alan C. Egge, Charles C. Hogge and Jennifer H. Jacobs
Date ____________
Please print this form, fill it out and take it with you to the doctor's office.
Please complete ALL blanks on the form. Your insurance company REQUIRES this information for billing.
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Name:  |
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Date: |
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Do you have or have you ever
had...
(check box for Yes or No) |
| General Medical History |
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Family
History
Does anyone in your
family have... |
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Diabetes
since when _____________? |
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Diabetes |
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| Do you take
insulin? |
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Heart
Disease |
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| High blood
pressure |
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Glaucoma |
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| Heart attack |
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Macular
Degeneration |
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| Heart
Disease |
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Other eye
disease |
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| Arthritis |
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Social History |
| Cancer |
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| Migraine
headaches |
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Occupation
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| Thyroid
disease |
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Yes |
No |
| Stroke |
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Do you smoke?
How
many cigarettes per day
? |
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| Lung disease /
Asthma |
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Do you drink
alcohol
How many drinks per week
? |
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Current Medications |
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| Kidney
disease |
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Allergies to
medicine
If Yes, please specify |
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| HIV |
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| TB |
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| Syphilis |
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Pervious
surgery
(If Yes, please specify) |
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| Other medical
problems |
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p1
Review of Symptoms
You Are Currently
Experiencing?
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CONSTITUTIONAL |
Yes |
No |
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(ear/nose/mouth/throat) Con't |
Yes |
No |
| Weight loss |
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Runny nose |
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| Weight gain |
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Sinus
problems |
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| Fatigue |
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Sore throat |
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| Fever |
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| CARDIOVASCULAR |
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BLOOD AND LYMPH
SYSTEMS |
| Chest pain |
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Easy
bruising |
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| Swelling of
feet |
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Swollen lymph
nodes |
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| ENDOCRINE |
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SKIN |
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| Excessive
thirst |
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Skin rash |
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Skin lesions |
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| RESPIRATORY |
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GASTROINTESTINAL |
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| Shortness of
breath |
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Heartburn |
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| Wheezing |
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Abdominal
pain |
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| Cough |
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| NEUROLOGICAL |
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MUSCLES
AND BONES |
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| Headaches |
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Arthritis |
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| Seizures |
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Weakness |
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| Weakness of
extremities |
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Easily broken
bones |
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| Numbness of
extremities |
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| EAR, NOSE, MOUTH,
THROAT |
PSYCHIATRIC |
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| Decreased
hearing |
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Depression |
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| Hearing aid
use |
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Nervousness |
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| For Office Use
Only |
Date |
Tech.
Initials |
Change |
No Change |
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Date |
Physician's
Signature |
Remarks
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