Welcome to Freedom Wellness Centers!
Past Medical History Form
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Today's date: *

 
What is your legal name?  (First, M.I., Last) *

 
Your past medical history is a vitally important part of establishing an accurate diagnostic assessment.  Your cooperation is appreciated.  
Directions:  please check either yes or no, and answer every question.  If you check yes to any of the following, there is an "other" field at the end of the line of questions, where you'll be asked to explain.  Thank you for your time and effort.  Completion of this form, although time consuming and tedious, gives the doctor the information needed to give you the best care possible.

 
General Health:

 
Weight Change? *

     
 
Fever/Chills? *

     
 
Sweats? *

     
 
Allergies? *

     
 
Anemia? *

     
 
Bleeding/bruising? *

     
 
Other? *

     
 
If yes to any of the questions in the general health section, please give a narrative description and explain:

 
Family History:

 
Diabetes? *

     
 
Thyroid disease? *

     
 
Tuberculosis? *

     
 
Renal disease? *

     
 
Hypertension? *

     
 
Heart disease? *

     
 
Musculoskeletal disease? *

     
 
Cancer? *

     
 
Other? *

     
 
If yes to any of the questions in the family history section, please give a narrative description and explain:

 
Endocrine System:

 
Heat/cold tolerance? *

     
 
Thyroid problems? *

     
 
Diabetes? *

     
 
Neck surgery/irradiation? *

     
 
Other? *

     
 
If yes to any of the questions in the endocrine system section, please give a narrative description and explain:

 
Eye, Ear, Nose and Throat (EENT):

 
Visual dysfunctions? *

     
 
Difficulty hearing/deafness? *

     
 
Tinnitis or ringing in the ears? *

     
 
Epistaxis or nose bleeds? *

     
 
Hoarseness? *

     
 
Sinusitis? *

     
 
Vertigo? *

     
 
Dental problems? *

     
 
Other? *

     
 
If yes to any of the questions in the EENT section, please give a narrative description and explain.

 
Gastrointestinal System:

 
Nausea/vomiting? *

     
 
Hematemesis or vomiting blood? *

     
 
Peptic ulcer disease? *

     
 
Dysphagia or difficulty swallowing? *

     
 
Indigestion/heartburn? *

     
 
Abdominal pain? *

     
 
Abdominal swelling? *

     
 
Hematochezia (bright, fresh blood per rectum) OR melena (dark/black stools)? *

     
 
Diarrhea? *

     
 
Constipation? *

     
 
Hernia? *

If yes, please specify the type in the "other" section
     
 
Hemorrhoids? *

     
 
Gallbladder disease? *

     
 
Liver disease? *

     
 
Pancreatitis? *

     
 
Alcohol intake? *

If yes, please specify type and amount in the "other" section
     
 
Other? *

     
 
If yes to any of the questions in the gastrointestinal system section, please give a narrative description and explain:

 
Pulmonary system:

 
Dyspnea or difficulty breathing? *

     
 
Cough/sputum production? *

     
 
Hemoptysis or coughing up blood? *

     
 
Wheezing/asthma? *

     
 
Tuberculosis/TB Exposure/TB test? *

     
 
Previous chest radiograph or x-ray? *

If yes, please list the date in the "other" section.
     
 
Respiratory infections/pneumonia? *

     
 
Environmental inhalation? *

     
 
Smoking history? *

If yes, in the "other" section, please indicate the number of packs per day, and how many years you have smoked.
     
 
Other? *

     
 
If yes to any of the questions in the pulmonary system section, please give a narrative description and explain:

 
Cardiovascular system:

 
Inadequate exercise level? *

     
 
Orthopnea (shortness of breath while lying flat) OR paroxsymal nocturnal dyspnea (shortness of breath and coughing at night)? *

     
 
Chest discomfort/pain? *

     
 
Palpitations or skipping heartbeat? *

     
 
Edema or swellling? *

     
 
Claudication (pain or weakness of muscles of the lower extremities related to exercise or exertion)? *

     
 
Hypertension or high blood pressure? *

     
 
Past heart disease? *

     
 
Rheumatic fever? *

     
 
Other? *

     
 
If you answered yes to any of the previous questions in the cardiovascular section, please give a narrative description and explain.

 
Genitourinary system:

 
Urinary frequency? *

     
 
Urinary urgency? *

     
 
Dysuria or painful urination? *

     
 
Nocturia or excessive urination during the night? *

     
 
Hematuria or blood in the urine? *

     
 
Urinary stream flow abnormality? *

     
 
Hesitancy/intermittency? *

     
 
Urinary incontinence or involuntary loss of urine? *

     
 
Urethral discharge? *

     
 
Genital lesions? *

     
 
Testicular mass/pain? *

     
 
Syphilis/positive serology? *

     
 
Gonorrhea? *

     
 
Urinary tract infections (UTIs)? *

     
 
Flank pain or kidney pain? *

     
 
Renal disease? *

     
 
If yes to any of the questions in the genitourinary system section, please provide a narrative description and explain:

 
Neurological system:

 
Headaches? *

     
 
Epileptic seizures? *

     
 
Episodic neurological symptoms:  (i.e. vision disturbances, transient attacks of any neurological symptom, difficulty speaking, weakness)? *

     
 
Dizziness/syncope? *

     
 
Sensory disturbances (i.e. numbness/tingling)? *

     
 
Weakness? *

     
 
Head trauma? *

     
 
Stroke? *

     
 
Other? *

     
 
If yes to any of the questions in the neurological system section, please provide a narrative description and explain:

 
Integument system (hair, skin, nails):

 
Itching? *

     
 
Rash? *

     
 
Change in mole(s)? *

     
 
Skin cancer? *

     
 
Other? *

     
 
If yes to any of the questions in the integument system section, please provide a narrative description and explain:

 
Musculoskeletal system:

 
Joint stiffness? *

     
 
Joint pain? *

     
 
Joint swelling? *

     
 
Low back pain? *

     
 
Neck pain? *

     
 
Thoracic (mid back) pain? *

     
 
Upper extremity problem? *

     
 
Lower extremity problem? *

     
 
Fracture/dislocations? *

     
 
Ligament sprain/muscle strain? *

     
 
Other injuries? *

     
 
If yes to any of the questions in the musculoskeletal system section, please provide a narrative description and explain:

 
Psychiatric:

 
Psychiatric problems or hospitalizations? *

     
 
Anxiety? *

     
 
Depression? *

     
 
Other? *

     
 
If you answered yes to any of the questions in the psychiatric section, please give a narrative description and explain.

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