HUNTERDON HEALTHCARE PARTNERS

DEIN M. SHAPIRO MD
PATIENT INFORMATION FORM
DATE:
PATIENT NAME:
Age: Birthdate: Date of last physical exam:
What is reason for visit?
FAMILY HISTORY:
Father: Alive: Deceased: Present health or cause of death
Mother: Alive: Deceased: Present health or cause of death
Brothers: # Alive: Health:
                # Deceased: Cause of Death:
Sisters: # Alive: Health:
                # Deceased: Cause of Death:
Children: # Alive: Sex, ages and health:
                # Deceased: Cause of Death:
Check illnesses which have occurred in any of your blood relatives:
Diabetes Cancer Bleeding tendency Heart disease Stroke High Blood Pressure Allergies
Other
SYMPTOMS: Check conditions you currently have or have had in the past year.
General Gastrointestinal Eye,Ear,Nose,Throat Men Only
Chills Appetite Poor Bleeding gums Breast lump
Depression/Nervousness Bloating Blurred vision Erection difficulties
Dizziness Bowel Changes Crossed eyes Lump in testicles
Fatigue Constipation Difficulty swallowing Penis discharge
Fainting Diarrhea Double vision Sore on penis
Fever Excessive hunger Earache Other
Forgetfulness Excessive thirst Ear discharge  
Headache Gas Hay fever Women Only
Loss of Sleep Hemorrhoids Hoarseness Abnormal Pap
Loss of weight Indigestion Loss of hearing Irg. Bleeding
Numbness Nausea Nosebleeds Breast Lump
Sweats Rectal Bleeding Persistent cough Menstrual Pain
  Stomach pain Ringing in ears Hot Flashes
Muscle/Joint/Bone Vomiting Sinus problems Nipple discharge
Pain, weakness, numbness in: Vomiting blood Vision-Flashes/Halos Painful intercourse
Arms       Hips     Vaginal discharge
Back        Legs Cardiovascular Skin Other
Feet         Neck Chest pain Bruise easily  
Hands     Shoulders High blood pressure Hives Last menstrual period?
  Irregular heart beat Itching
Genito-Urinary Low blood pressure Change in moles Last PapSmear?
Blood in urine Poor circulation Rash
Frequent urination Rapid heart beat Scars Last Mammogram?
Lack of bladder control Swelling of ankles Sores that won’t heal
Painful urination Varicose veins   Are you pregnant?
     

Conditions: Check conditions you currently have or have had in the past

Aids             High Cholesterol
Alcoholism             HIV Positive
Anorexia             Kidney Disease
Appendicitis             Liver Disease
Arthritis             Measles
Bleeding disorders             Migraine Headaches
Breast Lump             Miscarriage
Bronchitis             Mononucleosis
Bulimia             Multiple Sclerosis
Cancer             Mumps
Cataracts             Pacemaker
Chemical Dependency             Pneumonia
Chicken Pox             Polio
Diabetes             Prostate Problem
Emphysema             Psychiatric Care
Epilepsy             Rheumatic Fever
Glaucoma             Scarlet Fever
Goiter             Stroke
Gonorrhea             Suicide Attempt
Gout             Thyroid problems
Heart Disease             Ulcers
Hernia             Vaginal Infections
Herpes             Venereal Disease

 

Medications/Allergies:

List current medications you are taking:

 

Are you taking any herbal supplements? Please list supplements:

 

Are you taking any vitamins? Please list vitamins:

 

List allergies to medications and substances:

 

Health Habits: Check what substance you use and how much.

Caffeine Check if your work exposes you to the following:  
Tobacco Stress  
Drugs   Heaving Lifting Other
  Hazardous Substances

Your Occupation:

Signatures:

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 made in the completion of this form.

Signature: ______________________________________________________Date:

Reviewed by: ___________________________________________________Date:_______________________________________

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