General Review Form - Please print out and complete by hand.
A. General Yes No F. Cardiovascular Yes No
Do you worry a lot about your health?     Do you have pain, tightness or pressure in the front or back of your chest? If yes, is it when walking fast, working hard or when excited?    
Do you usually feel tired or worn out?     Have you ever been told that your electrocardiogram was abnormal?    
Do you feel depressed a lot of the time?     Do you have swelling of your feet or ankles?    
Have you recently noticed that heat or warm weather bothers you?     Does your heart ever beat fast or irregularly?    
Have you recently been drinking more water or fluids?     Do you have cramps in the calf muscles when you walk?    
Has there been any unusual weight gain or loss recently?     Do you ever awaken at night with severe difficulty breathing?    
B. Skin     Do your fingers or toes ever get cold, become numb or get very white or bluish?    

Have you noticed:Any change in the color of your skin?

     G. Gastrointestinal    
Any skin rashes or itching?     Have you recently had any changes in your eating habits?    
Unusually dry skin?     Are there any special foods that cause you to be upset or have stomach pains, nausea, etc.?    
Any growth on your skin that bother you?     Do you tend to burp a lot?    
Any sores or wounds that do not heal?     Have you recently noted any trouble swallowing?    
Any change in the color or size of warts?     Do you have a lot of indigestion or heartburn?    
C. Eyes     Have you ever vomited blood?    

Have you had: any pain in your eyes?

     Are you bothered with constipation?    
Glaucoma     Do you have frequent loose stools or diarrhea?    
Blurry vision?     Do you pass a lot of gas?    
Halos around lights?     Do you have a poor appetite?    
Change in vision?     Do you ever awaken at night with the feeling of fullness underneath your breastbone?    
D. Ear, Nose, Throat     Have you ever passed blood from your rectum?    
Do you have: Any trouble hearing?     Have you ever had black or tarry stools?    
Ringing or buzzing in your ears?     Have you noticed any recent changes in your bowel movements?    
Earaches or discharge from your ears?     Do you take laxatives regularly?    
A lot of nasal stuffiness?     Do you have frequent nausea and/or vomiting?    
Drainage down the back of your throat?     H. Genitourinary    
Frequent or severe nosebleeds?     Do you have: anything wrong with your genitals (privates)?    
Persistent hoarseness?     Burning or pain when you urinate?    
A lump in your throat?     To pass water frequently?    
A sore tongue or mouth?     To pass more water than you used to?    
Bleeding gums?     Trouble passing water?    
E. Respiratory
 		    To get up at night to urinate?    
Do you have Frequent chest colds?     Trouble with loosing urine when you cough or sneeze?    
A constant or bothersome cough?     A problem dribbling urine?    
Coughing of blood?     Have you ever passed blood in your urine?    
Sputum or phlegm between colds?     Have you had an operation to prevent pregnancy (vasectomy or sterilization, such as tubal ligation)?    
Difficulty breathing?     Men: Do you have prostate gland trouble?    
Have you noticed any wheezing or whistling in your chest?     .    

I. Musculoskeletal Yes No K. Women Only Yes No
Do you have a problem with back pain?     Did your menstrual periods start before you were 10?    
Do you have pain in your legs or feet?     Did your menstrual periods start after you were 15?    
Does back pain interfere with your work or activities?     Are your menstrual periods irregular?    
Do you have joint pain or stiffness?     Are your periods less frequent than every four weeks?    
Do you have trouble walking or using your hip or knee joints?     Do you use more than 10 pads or have to use a super sized pad or tampon for your periods?    
J. Central Nervous System     Do you pass clots with your periods?    
Do you have frequent or severe headaches?     Do you become bloated or gain weight just before your periods?    
Do you often have spells of diziness or faintness or lightheadedness?     Have you passed the menopause or change?    
Have you ever seen double?     Do you have hot flashes?    
Do you sometimes lose track of what happens around you for a short time?     Have you had any abortions or miscarriages?    
Do you sometimes lose the ability to speak for a few seconds?     Have you had any lumps in your breasts?    
Have you recently fainted, blacked out or lost consciousness?     Have you had any discharge from your nipples?    
Do you have trouble remembering recent events?     Have you ever used an intrauterine device (IUD)?    
Have you ever had convulsions or fits?     Have you used other birth control measures?    
Do you have numbness or tingling in your head, arms or legs?        
Do you consider yourself a nervous person?        
Do you cry a lot for no reason?        
Have you ever had an urge to commit suicide?        
Do you ever hear voices or see people when no one is around?        
Do you ever have a feeling that someone is trying to harm you?        

Additional Comments:

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Family History - check if any blood relative has or has had any of the following and enter relationship
Yes No Relationship Yes No Relationship
Stroke       Bleeding Tendency      
Cancer       Heart Attack      
High Blood Pressure       Stomach Ulcer      
Tuberculosis       Kidney Disease      
Diabetes       Goiter      
Leukemia       Arthritis      
Epilepsy       Colitis      
Suicide       Nervous Breakdown      
Migraine       Gout      
Asthma       Rheumatic Heart      
Hay Fever       Insanity      
Emphysema       Congenital Heart      
Past History - (Personal)
Have you had any of the following ilnesses?
Yes No
Rheumatic Fever    
Angina Pectoris    
Heart Attack    
Other Heart Disease    
High Blood Pressure    
Anemia    
Kidney Disease    
Gout    
Hay Fever    
Asthma    
Frequent Lung Infections    
Emphysema    
Diabetes    
Cancer    
Frequent Kidney or Bladder Infections    
Nervous Breakdown    
Thyroid Disease    
Stomach Ulcers    
Gallbladder Disease    
Jaundice    
Hepatitis    
Colitis    
Arthritis    
Migrane Headache    
Other:

Personal Habits

1. Check if you regularly smoke:
___Cigarettes: Number per day_______        ___Pipe      ___Cigars
How long have you been smoking: _____ years

2. Check if you regularly drink:
___Hard liquor: __1-3 oz per day   __over 3 oz per day
___Beer: __1 bottle per day   __2 bottles   __3 or more
___Wine: __1 glass per day   __2 glasses  __3 or more

3. Do you drink coffee: __Yes     __No   ___3 or more cups

4. Do you have difficulty sleeping? __Never   __Often   __Sometimes

5. Do you awaken very early in the morning without apparent cause
and find it difficult to fall asleep again?
__frequently   __occasionally   __rarely

Operations: List and indicate approximate year:
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Hospitalizations (other than operations). List reasons and approximate dates:
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Serious injuries (other than above). List and give approximate dates:
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Diagnostic X-Rays: List and give approximate dates:
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Immunizations: Please give date:
Smallpox___________  Polio ________________
Typhoid____________ Tetanus______________

Are you allergic to any medications: __Yes __No
If YES, please list medications and the reaction you had to them:
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  MEDICATIONS - check which of the following, if any, you are regularly taking:    
  Asthma or wheezing medicine   Sleeping pills or tranquilizers
  Aspirin, Bufferin, Anacin, Tylenol or similar products   Thyroid medicine
  Blood pressure pills   Stomach or digestive medicine
  Cortisone, Prednisone   Weight reducing pills
  Cough medicine   Blood thinners or Coumadin
  Digitalis or heart medicine   Dilantin
  Hormones or birth control pills   Water pills, diuretics
  Insulin or diabetic pills   Antibiotics
  Iron or poor-blood medications   Phenobarbital or barbituates
  Laxatives   Vitamins
    Other Drugs (list below)
List other drugs or injections: _____________________________________________________________________
OCCUPATIONAL Yes No MARITAL/FAMILY Yes No
Are you presently employed?     Have you been married more than one time?    
Are you dissatisfied with your present type of work?     Has there been a recent change in your marital status?    
Does your work involved unusual work, exposure to dust, noise, radioactivity, etc?     Does your age and your spouse's age differ by more than 10 years?    
Do you have more than one job?     Are there any problems with your married life?    
Do you work more than 60 hours a week?     Do you have any sex problems?    
Do you get along poorly with your fellow employees and/or your supervisors?     If a widow or widower, have you had difficulty adjusting to your spouse's death?    
Are you unable to perform any work because of disability?     If a parent, do you have any serious problems with your children?    
Are you retired?     Is your present home life causing unhappiness?    
If retired, have you had difficulty adjusting to retirement?     Have there been any deaths in your family or among close friends in the past year or two?    
If a housewife, do you find your housework difficult?     Does anyone in your family have a serious illness or disability?    
If a housewife, are you unhappy with your housework?     Does anyone in your family have a drug or alcohol problem?    
SOCIAL HISTORY          
Have you recently lived or traveled outside the U.S.?     Do you have special food customs or restrictions?    
Did you complete a high school education?     Have you ever been treated for a drinking problem?    
Did you attend and/or complete college?     Do you exercise fewer than 3 times a week?    
Were you rejected from the military service?     Do you have a hobby or hobbies?    
Have you ever been rejected for life or health insurance or had to pay an extra premium?     Are you active in political, community or church activites?    
Do you eat fewer than 3 meals a day?          

Please list your hobby or hobbies:
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Patient Name_______________________________________________________ Date:______________

Please print this form and the OTHER TWO FORMS ONLINE. Thank you.
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