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A history of cancer 4. Asthma 5. Diabetes 6. Obesity 7. Acne 8. Hepatitis C 9. Liver cirrhosis 10. Diabetes or kidney failure 11. Scleroderma 12. Stroke 13. Other 13. Any disease requiring hospitalization 14. A chronic, debilitating condition Other Comments: You have had a history of a cancer, liver disease, stroke or a heart condition. Are you currently taking any medicine (e.g., NSAIDs) for which you are not on treatment? Yes No DO YOU FEEL SLEEP-ON-A-STIN AND/OR REMIND YOU OF A TUMOR TO ANY DEGREE? Yes No Have you tried to quit smoking? Yes No Do you have or have you ever had: 1. Sudden, severe headaches 2. Frequent chest pains/shortness of breath 3. Shortness of breath that is difficult to correct on breathing, especially in pregnancy 4. Dizziness, faintness, or headache lasting for 6-12 hours (or can be relieved with rest or light activity) 5. Increased heart rate/sudden shortness of breath 6. Frequent, severe stomach aches/nausea 7. Any unusual changes in your skin (e.g., rash, peeling/cracking, bleeding, pain/sensitivity/tension/redness/blisters) or mucous membranes (e.g., difficulty urinating during/after urination, discharge, itching, eczema) 8. Constipation 9. Weight loss 10. Seizures 11. Increased body odor or unusual taste/smell 12. Sudden (with no obvious cause) increased sensitivity to pain (e.g., burning, pins-and-needles sensation) 13. Trouble concentrating 14. Changes in sleep (e.g., difficulty falling asleep, trouble staying asleep) 15. Changes in mood, appetite/energy level Did you know you had a high temperature for at least 2 weeks? Yes No DO YOU FEEL DEPRESSED, ALARMED, ALMOST UNSATISFIED, OR AT ALL? Yes No Have you ever had: 1. Any serious illness, injury, or condition 2. An illness or injury that affected your ability to work 3. Any injury sustained during military service or in or from the armed forces 4. If pregnant, a history of miscarriage (lack of pregnancy) or stillbirth 5.

Hey how are you doing today my name is Kathy very nice to meet you I'm going to be handling the paperwork with you just pull your pages give our patients the option they would like to print these pages off at home and fill it out and then just simply bring it back to us oh you can come in for an appointment and fill it out then or as we're doing today you can set up an appointment with me and I can help you go through the pages questions medical history mm-hmm, so I'm going to be helping you through this process eight pages to fill out together that the last page doesn't count its one question together we'll be able to finish this rather quickly we're just going to go through this medical history and screening form together okay there are different sections and I just need you to be honest about your medical history your family background mm-hmm will benefit you in the long run as we go through this form if you have any questions for me comments or concerns please let me know, and I can actually include that in your file mm-hmm it's very helpful and useful for your doctors and your nurses any questions during this please don't hesitate to ask that's why we set up this meeting did you have any questions for me before we started this first page here alright, so we're gonna start with just your general information okay can I get your name did you have a middle name that you wanted to add to this can I get your address okay MMM city you have an apartment number or is that just a house or condo no here contact numbers MMM we usually prefer to do you have to like a home number and a cell phone or a home at work or okay so the first one it's a cell phone just go to that that your primary contact number and did you have mm-hmm the second number perfect and can you just verify your birthday for me months hey dear no family physician or primary care provider you are new to our clinic right so do you have your previous doctors do you have out their phone number by chance your phone feel free to look it up oh I'm at number is their address or just travel the clinic name yeah when you look up there at that sign and what city is that in easy Anna all right do we have permission to receive patient file documents regarding your health and hoping from your previous position that'll be helpful for us and if you can just this line right here just as a verification that you give me permission to have those files sent over so just straight there hmm and if you can just initial right so how can I ask your marital status are you single married divorced or widowed and how do you classify your sex now FEMA education did you complete grade school okay and junior high school any form of college and if so how many can I come your occupation position and what's your employer's father or just the general city and what about a work number the best way to contact your manager supervisor just going to go ahead and keep these order for us in your file here next up we're going to...