Garrison Family •Personal Details •Insurance •Emergency Contact •Reason for Visit •Patient History First Name*?Just your First NameMiddle InitialsLast Name*Title*Marital Status*Age*SexMrMrsMissMsOtherSingleMarriedDivorcedSeparatedWidowedMaleFemaleDate of Birth*Social Security No*Drivers License NoEthnicity*RaceSpoken LanguageWhiteBlack/African AmericanHispanic/LatinoAsian/Pacific IslanderNative AmericanMissing/UnknownOther Home Address*POB / Apt #City*State*Zip*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingEmail Address*Day Phone*Cell PhoneCurrent OccupationEmployerEmployer PhoneEmployer Address Primary Insurance NameType of InsurancePPOPPSMedicareManaged Care / HMOOtherAddress (if different)Home Phone (if different)Subscribers NameRelationship to SubscriberSubscribers Date of BirthSelfSpouseChildOtherCo-Pay AmountGroup PolicyID No Secondary Insurance NameType of InsurancePPOPPSMedicareManaged Care / HMOOtherSubscribers NameRelationship to SubscriberSubscribers Date of BirthSelfSpouseChildOtherCo-Pay AmountGroup PolicyID No Name of Local Individual*Relationship*SpouseChildOtherAddress*Home Phone*Cell PhoneWork Phone Authorization I authorize release of my medical information at any time to the following personRelationship to PatientInformation ReleasedI authorize releaseSpouseGuardianOtherAllTest resultsHealth statusOtherYesNo Chief Medical Complaint*Date of Last Physical ExamLocation of the ProblemPain Level 1-10When did you first notice the problem?AbdomenBackLegOther12345678910 Severe2 days ago2 weeks ago1 month agoOtherDoes anything help or make worse?Is the problem constant or variable?Moving aroundStanding upLying on my sideOtherDull then sharpVery sharp then leavesAlways thereOtherIs anything else occurring at the same time?If yes, please explainYesNo List all serious illnesses in your immediate family. (e.g. diabetes, tuberculosis, breast cancer, heart disease, etc.) Please indicate if living or deceased, cause of death and age.MotherFatherGrandparentsSiblingsOtherList any personal past illnessAre you on a special diet?Do you have any allergies?YesNoYesNoIf yes, please explainIf yes, please explain Surgical HistoryDate HistoryTodayHistoryTodayGeneralHistoryTodayChange in appetiteHistoryTodayWeight gainHistoryTodayWeight lossHistoryTodayPainHistoryTodayDifficulty sleepingHistoryTodaySleep problemsHistoryTodayNight sweatsHistoryTodayFeverHistoryTodayChillsHistoryTodayDizzinessENMTHistoryTodayChange in hearingHistoryTodayEar dischargeHistoryTodayEar PainHistoryTodayRinging in the earsHistoryTodayNasal dischargeHistoryTodayNasal obstructionHistoryTodayNose bleedsHistoryTodaySinus painHistoryTodaySinus / nasal congestionHistoryTodayMouth problemsHistoryTodayBleeding gumsHistoryTodayDenture problemsHistoryTodayDry mouthHistoryTodayMouth soresHistoryTodayTongue painHistoryTodayDifficulty swallowingHistoryTodaySore throatHistoryTodayChange in voiceHistoryTodayHoarseness HistoryTodayHistoryTodayEyesHistoryTodayEye dischargeHistoryTodayEye drynessHistoryTodayExcessive tearingHistoryTodayEye irritation / itchingHistoryTodayPainHistoryTodayRed eyesHistoryTodayBlurred visionHistoryTodayDouble visionHistoryTodayFlashing lightsHistoryTodaySeeing spotsCardiovascularHistoryTodayChest painHistoryTodayChest pressure / discomfortHistoryTodayHeart troubleHistoryTodayHeart murmurHistoryTodayLightheadednessHistoryTodayPalpitationsHistoryTodayLeg crampsHistoryTodaySwellingEndocrineHistoryTodayExcessive appetiteHistoryTodayExcessive thirstHistoryTodayExcessive urinationHistoryTodayHeat intoleranceHistoryTodayCold intoleranceHistoryTodayHair lossGastrointestinalHistoryTodayAbdominal painHistoryTodayNauseaHistoryTodayVomitingHistoryTodayHeartburnHistoryTodayConstipationHistoryTodayDiarrhea HistoryTodayHistoryTodayGenitourinaryHistoryTodayLosing control or urineHistoryTodayUrinary urgencyHistoryTodayNight time urinationHistoryTodayFrequent urinationHistoryTodayBurning or pain urinatingHistoryTodayDifficulty urinatingHistoryTodayReduced streamHistoryTodayDribblingMusculoskeletalHistoryTodayJoint painHistoryTodayMuscle painHistoryTodayStiffnessHistoryTodayNeck painHistoryTodayBack painIntegumentaryHistoryTodayBruisingHistoryTodayItchingHistoryTodayMole changesHistoryTodayRashHematologic / LymphaticHistoryTodayEasy bleeding or bruisingHistoryTodayAnemiaHistoryTodaySwollen glandsAllergic / ImmunologicHistoryTodayImmunodeficiencyHistoryTodayHay fever history HistoryTodayHistoryTodayRespiratoryHistoryTodayDifficulty breathingHistoryTodayWheezingHistoryTodayCoughNeurologicalHistoryTodayHeadachesHistoryTodayMigrainesHistoryTodaySeizuresHistoryTodayFaintingHistoryTodayRinging in the earsHistoryTodayShort term memory problemsHistoryTodayLong term memory problemsHistoryTodayConfusion / DisorientationHistoryTodayDelusionsHistoryTodayChange in personalityHistoryTodaySpeech changesHistoryTodayFacial weakness / numbnessHistoryTodayWeakness / numbness in armHistoryTodayWeakness / numbness in legHistoryTodayNumbness / tinglingHistoryTodayMuscle weaknessHistoryTodayLoss of limb useHistoryTodayTremorsHistoryTodayBalance problemsHistoryTodayChange in gaitHistoryTodayLosing control of gait or bowelPsychiatricHistoryTodayAnxietyHistoryTodayNervousnessHistoryTodayDepressionHistoryTodaySadnessHistoryTodayHallucinationsHistoryTodaySuicidal thoughtsHistoryTodayStressHistoryTodayBipolar or Schizophrenia Tobacco use?Alcohol use?Regular exercise?Caffeine?YesNoYesNoYesNoYesNoIf yes, how much?If yes, how much?If yes, how much?If yes, how much?Immunizations: (Please list approx date of last, or provide copy of immunization record)TetanusPneumoniaInfluenzaZoster (Shingles)HPVLast TB screeningResults?Chest x-ray done?PositiveNegativeYesNoHave you tested or vaccinated for Hepatitis A, B or C? ABC Are you currently taking any medication? (Please list name/does/frequency if known)NameDoseFrequency I wish to be contacted in the following manner (check all the apply): Home telephone: Okay to leave a message with detailed informationLeave message with call back number ONLY Written communication: Okay to mail to my home addressOkay to mail to my work/office addressOkay to fax to the number: Work telephone: Okay to leave a message with detailed informationLeave message with call back number ONLY Other: Other
