History & Review of Systems (Connersville 2022)

History & Review of Systems
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
History

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	Alive Yes/No	Age	Cause of Death
Self
Father
Mother
Sibling(s)
Grandmother
Grandfather

	Self	Father	Mother	Sibling(s)	Grandmother	Grandfather
Living
Alcoholism
Anxiety
Asthma
Bleeding Disorder
Cancer
Depression
Diabetes
Heart Disease
Hepatitis C
High Blood Pressure
High Cholesterol
HIV/AIDS
Kidney Disease
Liver Disease
Mental Illness
Migraines
Stomach Issues/Reflux
Stroke
Thyroid Disease

Medications

(If you have more medications than can be listed, please bring ALL medications/list with you to your visit)

	Drug Name	Strength	Frequency Taken
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Allergies

	Drug	Reaction
1.
2.
3.
4.
5.

Surgeries

	Surgery	Year/Age	Surgery	Year/Age
1.
2.
3.
4.
5.

Social History
Education

Less than 8th-GradeHigh School2 Year College4 Year CollegePost Graduate
Caffeine

NoneOccasionalModerateHeavyNumber of Cups/Cans Per Day
Marital Status

SingleMarriedDivorcedSeparatedWidowedDomestic Partner
TobaccoYes   No
CigarettesPacks   packs/day
Chew  Chews   /day
CigarsCigars/day
Number of Years QuitYears Quit
Do you use recreational or street drugs?
If yes, list Drug Drug Drug Drug
Exercise Level

NoneOccasionalModerateHigh
Date of Last Dental Exam:
Review of Systems

Please Check all That Apply
Allergic/Immunologic

Frequent SneezingHivesItchingRunny NoseSinus Pressure
Cardiovascular

Arm Pain on ExertionChest Pain on ExertionChest Heaviness/Pressure on ExertionIrregular Heart BeatsKnown Heart MurmerLight Headed on StandingShortness of Breath When LyingShortness of Breath When WalkingSwelling/Edema
Constitutional

Exercise IntoleranceFatigueFeverWeight Change (Loss/Gain)
Ear / Nose / Mouth / Throat

Bleeding GumsDifficulty HearingDizzinessDry MouthEar PainFrequent InfectionsFrequent NosebleedsHoarsenessMouth BreathingMouth UlcersNose / Sinus ProblemsRinging in Ears
Endocrine

FatigueIncreased Thirst / Hunger / Urination
Gastrointestinal

Abdominal PainBlack or Tarry StoolBlood in StoolChange in AppetiteFrequent IndigestionHemorrhoidsTrouble SwallowingVomitingVomiting BloodDate of Last Colonoscopy
Genitourinary

Blood in UrineDifficulty UrinatingIncomplete EmptyingIncreased Urinary FrequencyUrinary Loss of Control
Hematologic / Lymphatic

Easy Bruising and BleedingSwollen Glands
Integumentary (skin)

Changes in MolesDry SkinEczemaGrowth/LesionsItchingJaundice (Yellow Skin/Eyes)Rash
Musculoskeletal

Back PainJoint PainMuscle AchesMuscle Weakness
Neurological

DizzinessFaintingHeadachesMemory LossMigrainesNumbnessRestless LegsSeizuresWeakness
Psychiatric

Alcohol OveruseAnxiety/StressDepressionDo not feel safeManiaSleep Problems
Respiratory

CoughCoughs up BloodShortness of BreathSleep ApneaSnoringWheezing
Should be Empty:

History & Review of Systems

History

Medications

Allergies

Surgeries

Social History

Review of Systems