Classic City Cardiology, P.C. - Medical History
 Name Today's Date , 2003
Age Birthdate , Date of last physical examination ,
What is the reason for you visit?
SYMPTOMS               Check symptoms you currently have or have had in the past year

GENERAL

GASTROINTESTINAL

CARDIOVASCULAR

EYE, EAR, NOSE THROAT
Chills Poor Appetite Chest pain/pressure Bleeding Gums
Depression Bloating High Blood Pressure Blurred Vision
Dizzines Bowel Changes Irregular Heart Beat Difficutly Swallowing
Fainting Constipation Low Blood Pressure Nosebleeds
Forgetfulness Excessive Hunger Poor Circulation Persistent Cough
Headache Excessive Thirst Rapid Heart Beat Vision-Flashes
Loss of Sleep Diarrhea Swelling of Ankles Vision-Halos
Loss of Weight Gas Varicose Veins
Fever Hemorroids

Pain or numbness in arms
Nervousness Indigestion  
Numbness Nausea   SKIN

Sweats

 Rectal Bleeding   Bruise Easily
    Stomach Pan  
GENITO-URINARY Vomiting               WOMEN ONLY
Frequent Urination Vomiting Blood          Date of Last Menstrual Period
           Are you pregnant?
CONDITIONS              Check conditions you currently have or have had in the past year
AIDS Chicken Pox High Blood Pressure Psychiatric Care
Alcoholism Diabetes HIV Positive Rheumatic Fever
Anemia Emphysema Kidney Disease Scarlet Fever
Anorexia Epilepsy Liver Disease Stroke
Arthritis Glaucoma Measles Suicide Attempt
Asthma Goiter Migraine Headache Thyroid Problems
Bleeding Disorders Gonorrhea Mononucleosis Tonsitis
Breast Lump Gout Multiple Sclerosis Tuberculosis
Bronchitis Heart Disease Mumps Typhoid Fever
Bulimia Hepatitis Pacemaker Ulcers
Cancer Hernia Pneumonia Vaginal Infections
Cataracts Herpes Polio Venereal Disease
Chemical Dependency High Cholesterol Prostate Problems

MEDICATIONS
List medications you are currently taking
How often per day
 ALLERGIES TO MEDICATION
     
     
     
     
     
     
     
     
Pharmacy Name Phone  

FAMILY HISTORY     Fill in the information about your family
 Relation 
 Age 
 State of 
Health
 Age at 
Death
Cause of Death
Check if any of your blood relatives had the following
Disease
Relationship to you
Father         Arthritis, Gout  
Mother         Asthma, HayFever  
Brothers         Cancer  
          Rheumatic Fever  
          Diabetes  
Sisters         Heart Disease, Strokes  
          High Blood Pressure  
          Kidney Disease  
Children         Tuberculosis  
          Thyroid Disease  
          Other  

HOSPITALIZATION
Reason for Hopitalization and Outcome
Surgery Performed if any
Year
Hospital
       
       
       
       
       

HEALTH HABITS
Check which substances you use and describe how much
OCCUPATIONAL CONCERNS
Check if your work exposes you to the following
Caffeine Stress
Tobacco Heavy Lifting
Drugs Other
Alcohol  
  Your Occupation:

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

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Signature
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Date
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