Perimeter North Family Medicine
Patient Questionaire Date:
Name: Date of Birth:
Past History:
Please list any chronic medical conditions you have:
1. 4.
2. 5.
3. 6.
Please list any surgical procedures you have ever had, including year of procedure.
1. 4.
2. 5.
3. 6.
Please list the date of your last Flexible Sigmoidoscopy.
Family History:
Living Deceased List any chronic illnesses or cause of death.
Mother
Father
Sisters-how many?
Brothers-how many?
Medications:
List medications you currently take on a daily basis including dosage and frequency.
1. 4.
2. 5.
3. 6.
ALLERGIES:
Social History:
Occupation
How much alcohol do you consume on the average day?
How much tobacco product do you consume on the average day?
How many children do you have?
Living Ages/Gender Deceased
Ages at death and gender
Do you exercise on a regular basis and if so, which activities? _______________________________
______________________________________________________________________________
List leisure time activities. ______
Women
only. Reproductive history.
Please list the outcome of each pregnancy.
Date of last Pap Smear Mammogram
Perimeter North Family Medicine
Review of Systems: Date:
Have you recently experienced any of the following symptoms?
Please check, and give details of any positive answers below.
Yes No
1.
General symptoms – change in weight, change in appetite, fever, night
sweats, fatigue.
2.
Eyes – blurred vision, pain in eye, dry eyes, discharge, double
vision.
3.
Ears, nose & throat – sore throat, difficulty swallowing, ear pain,
hearing difficulty, ringing in ears, hoarseness, sinus trouble.
4.
Heart – chest pain, palpitations, shortness of breath, ankle swelling.
5.
Lungs – shortness of breath, coughing, coughing up blood, wheezing,
sputum.
6.
Gastrointestinal – constipation, diarrhea, change in bowel pattern,
abdominal pain, nausea, vomiting, blood in bowel movements,
black bowel movements.
7.
Kidneys/Genital – painful urination, blood in urine, frequency,
incontinence, voiding more that once at night, sexual dysfunction.
8.
Bones/Joints – painful or swollen joints, loss of strength, back pain.
9.
Skin/Breast – skin rash, change in mole, jaundice, nipple discharge,
breast lump.
10.Nervous
System – headaches, dizziness, memory loss.
11.Psychologic
– depression, mood swings, insomnia.
12.Endocrine
– excessive thirst, cold or heat intolerance.
13.Blood/Lymphatic
System – easy bruising, swollen glands.
14.Allery/Immune
System – allergy problems, frequent infections,
‘hives”.
Details of positive answers:
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