ࡱ>    !Root EntryZ O2ߛi"CONTENTS >CompObjVSPELLING8____________ ___________________________ __________________________ _______________________________ ___________________________ __________________________ _______________________________ ___________________________ __________________________ _______________________________ ___________________________ __________________________ _______________________________ ___________________________ __________________________ _______________________________ ___________________________ __________________________ YOUR FAMILY S MEDICAL HISTORY: Does or did anyone in your family other than yourself have: Breast cancer yes ____ no ____ Inflammatory Bowel Disease yes ____ no ____ Colon cancer yes ____ no ____ Heart Attack yes ____ no ____ Stroke yes ____ no ____ Other cancers: ________________________________________ Other medical problems: _____________________________________________________________________ YOUR SOCIAL HISTORY: Marital status: _____________ Number of children: ______ Occupation: ______________________ Do you smoke or use tobacco? _______ Have you ever? ______ IF SO: How many packs per day? ______, And how many years? _______. If you have quit smoking, when did you? _______ Do you drink beer or alcohol? none ______ small amount ______ moderate ______ large amount ______ SYSTEM REVIEW: Constitutional Symptoms Gastrointestinal Ear/Nose/Throat/Mouth Fever Yes No Abdominal Pain Yes No Ear Infection Yes No Chills Yes No Change in appetite Yes No Sore Throat Yes No Weight Loss Yes No Nausea and Vomiting Yes No Sinus Problems Yes No Yellow Jaundice Yes No Constipation Yes No Respiratory Eyes Diarrhea Yes No Wheezing Yes No Blurred Vision Yes No Blood in Stool Yes No Frequent CouCHNKWKS >TEXTTEXT#FDPPFDPP&FDPPFDPP(FDPCFDPC*FDPCFDPC,STSHSTSH.STSHSTSH.2SYIDSYIDP.SGP SGP d. INK INK n.BTEPPLC r. BTECPLC . FONTFONT.<STRSPLC .:PRNTWNPR(/\ FRAMFRAM<TITLTITL =4DOP DOP @=(_________________ YOUR PATIENT NAME: _________________________ DATE: _______________ CHART # __________ MAIN PROBLEM(S) for which you came today: __________________________________ YOUR PAST MEDICAL HISTORY: Have you ever had or been treated for: Sugar Diabetes: no: _____ yes: _____ for how long? ________Insulin? yes _____ no _____ Heart Attack: no: _____ yes: _____ when? _____________________________________ Other heart trouble: no: _____ yes: _____ what kind? _________________________________ Stroke: no: _____ yes: _____ when? _____________________________________ High blood pressure: no: _____ yes: _____ for how long? ________________________________ Cancer: no: _____ yes: _____ what kind? ___________________________________ Any other medical problems: ____________________________________________________________ Women Only: How many pregnancies have you had? ______ How many babies born? ______ Last menstrual period: ___________ Are you using birth control? _____ Type: ________ YOUR PAST SURGICAL HISTORY: ANY ALLERGIES: What operations have you had and when? Are you allergic to any medications or dye? ____________________________________________ ______________________________________ ____________________________________________ ______________________________________ ____________________________________________ ______________________________________ ____________________________________________ ______________________________________ ____________________________________________ ______________________________________ MEDICATIONS YOU ARE TAKING: Please list the current medications you are taking, their dosages, and how often you take them (include over the counter meds): ___________________gh Yes No Neurological Cardiovascular Asthma Yes No Sudden Weakness Yes No Chest Pain Yes No Psychological Extremity Paralysis Yes No Shortness of Breath Yes No Depression Yes No Tremors/Shakes Yes No Swelling of Feet Yes No Excessive Anxiety Yes No Dizzy Spells Yes No Skin Sleeplessness Yes No Numbness/tingling Yes No Skin Rashes Yes No List any other symptoms that bother you: Endocrine Boils Yes No Excessive Thirst Yes No Wounds Yes No ___________________________________ Too Hot/Too Cold Yes No If yes, where? ______________ Tired or Sluggish Yes No ___________________________________ Musculoskeletal ________________________________ Joint Pain Yes No ___________________________________ Neck Pain Yes No Back Pain Yes No ________________________________ ___________________________________ P. O. Box 476 ALAN F. JACKS, M. D. Phone: 828-874-0555 Rutherford College, NC 28671 _______R^`^lr $ & 2 4 6 V@B\^bDn,jl (|& H!!&""$## $:$$$$$$$$%%(2"'( ) @S =& h 2  :JdPDl<HVdj>RR ^ Z!$##$$$$X%%%z "PS"  "|"  "  "!"   "!"   "  "!"  "!" %% "|"  77 " "  "tt$%&(%%*,(7Times New Romanz~ " " "XXK*KG0HP Photosmart 2700 series!@h߀ odBeRLdExplorerdHBeںںHP Photosmart 2700 series0 series,LocalOnly,DrvConvert+winspoolHP Photosmart 2700 seriesPhotosmart2700seriesF"D""0n"$c"` "``""A."@"D""0n""` "``"."History medical forms.wps("/""`" (" (2"'( ) @S  Z O2Quill96 Story Group Class9qyyy{6 y<