:thumbup: Please help me fill out the medical history questionnaire.. I have no idea what to put or what they want me to write.
1. Musculoskeletal (Bone/Muscles) system review Bursitis
Tendonitis
Arthritis or swollen joints
Back problems
Sciatica
Necl pain
Muscle or extremity weakness
Morning stiffness
Jaw pain, popping or clicking
X rays
2. Please comment on above question (14) answers.
3. Metabolic system review Diabetes mellitus
Gestational diabetes
Thyroid problems or disorder
Are you on or have been on thyroid replacement medications?
Elevated cholesterol or triglycerides
4. Do you have any of the following ? Rheumatic Fever
Pneumonia
COPD
Pleurisy or other lung disease such as sarcodosis
Pulmonary Artery Hypertension
High Blood pressure
Heart Attack
Diabetes Mellitus
GERD
Esophagitis
Gastric Ulceration
Duodenal ulceration
Helicobactor pylori infection
Upper Gastrointestinal bleeding, bleeding ulcer
Esophageal or Gastric Varices
Congenital or acquired intestinal telangiectases (Sturge Weber Syndrome)
Crohn's Disease
Atresia's or Stenosis of the GI tract
Cirrhosis
acute or Chronic Pancreatitis
Anemia
Bleeding Tendencies
Psoriasis
Cataracts
Radiation Treatement
Thyroid dsease
Accidents or major trauma
Other hospitalizations
Addiction to alcohol or drugs (must be clean and sober 5 yrs with proof)
Bi-polar disorder (patients have to document compliance with medication and follow up)
Have you ever been diagnosed with a connective tissue disease, such as Lupus, Scleroderma, or Sicca syndrome? Anyone in your immediate family?
Are you on large doses of Steroids?
Other illneses
5. Please comment on above question (20) answers
6. Systems Review General Weight loss or Gain
Chills
Fever
Night Sweats
Weakness
Easy fatigability
Intolerance to Cold or Heat
7. Please comment on the above question (6) answers.
8. Please comment on above question (12) answers.
9. Respiratory (Lungs) Shortness of Breath
Cough up blood
Pleurisy
Chronic Cough
Asthma
Abnormal Chest Xray
Last Chest X ray
10. Psychiatric Depression
Bipolar disorder
Anxiety (nervousness)
Suicide thoughts or attempts
Psychiatric trreatment
Counseling
11. Genitourinary (kidneys) system review Get up at night to urinate
Kidney or Bladder infections
Difficulty with Urination
Blood in Urine
Kidney Stones
Surgery
Prostate Problems
Kidney xrays or ultrasounds
12. Plese comment on above question (18) answers
13. Please comment on the above question (4) answers.
14. Please use this area to tell us about any of the diagnoses, hospitalizaations, or other major illness you might have in the 1st question.
15. Please comment on above question (24) answers
16. HEENT System Review Headaches
Sudden vision changes
Glaucoma
Dry eyes
Do you wear glasses or contacts
Have you had any eye surgery such as LASIK or LASEK or RK
If Diabetic, when was your last retinal eye exam?
Ear infections
Vertigo
Nose Bleeds
Allergies
Sinusitis
Dentures Bridges
Mouth ulcers
Hoarseness
Dry mouth
SICCA syndrome
17. GI system review Difficulty swallowing
food getting stuck
Indigestion
Change in Bowel Habits
Blood in stool
Dark or tar colored stools
Surgery
Vomiting
Nausea
Diarrhea
Constipation
Irritable Bowel Syndrome
Pain
Vomiting Blood
Jaundice
Gallbladder problems
Pancreatitis
Stomach Xray
Colon Xray
Gallbladder Ultrasound
EGD or colonoscopy
18. Please comment on above question (16) answers
19. Please Comment on above question (10) answers
20. Neurological (Brain/Nerves) system review Dizziness
Fainting or Blackouts
Irritability
Seizures (epilepsy)
Numbness
Peripheral neuropathy (nerve damage)
Spasm
Xrays
Nerve conduction studies
21. GYN History for Women Age at Menarche: Age first preganancy: Age at Menopause: Last mensturual period: Number of Pregnancies: Miscarrages, abortions?" Eclampsia or premature delivery? Number of living children: Did you breast feed?
22. Please comment on above question (22) answers
23. Heart System Review Chest pain or discomfort
High Blood pressure
Heart Murmur
Palpitations or Fluttering
Edema(swelling of feet)
Myocardial infarction (heart attack)
Pacemaker
Coronary angiogram
Angioplasty or Stent placement
Recent Stress test or cardiac evaluation for chest pain
24. Pease comment on the above question (8) answers.
25. Skin Review Ulcers or Nodules
Rash
Easy Brusining
Unusal change in Body hair
Skin Cancer
Recent Change in a mole
Color Chnage in fingers
Tightness