Patient History

Please complete this form to speed up the processing of your information when you arrive at our office.
After you complete the pertinent information print a copy to your printer and take with you at the time of exam.
Patient Name

Do you have a history of Allergy to Medications Yes   No    (Z88.0-Z88.8 or V14.0-V14.8)
What medicine(s) are you allergic to?

I have a Medicine Allergy, but I DON'T KNOW the Medicine?   Yes   No    (Z88.9 or V14.9)

Do you have a history of Allergy to Food or Other Substances Yes   No  
Please list Specific Allergy Eleciting Agents?
(Z91.010-Z91.048 or V15.01-V15.09)

Type of reaction you have had with ANY of the above allergies (Check all that apply):
  Decreased Heart Rate Difficulty Breathing Hives
  Decreased Blood Pressure Cardiac Arrest  

Do you have other problems with Interal Organs or Deficiencies?
  Please check and list problems below:
Cardiorespiratory Problem 
Digestive Problems 
Urinary Problems 
History of Kidney Failure   Yes    No
Are you on Dialysis?   Yes    No
Do you have a history of Cancer?   Yes    No
If Yes, what organ or type 

Do you have Multiple Myeloma Yes    No    (C90.01-C90.11 or 203.01-203.11)

Do you have Diabetes Mellitus Yes    No    (E11.9,E10.8-E10.65 or 250.00-250.93)
Do you take:   Glucophage or    Metformin?  

Do you have Sickle Cell Anemia Yes    No    (D57.1-D57.819 or 282.60-282.69)

Have you had a recent Heart Attack (Mycardial Infarction)?   Yes    No    (I21.09-I21.3 or 410.00-410.92)
If Yes, provide Date: 

History of Unstable Angina (Intermediate Coronary Syndrome)?   Yes    No    (I20.0 or 411.1)

Do you have Hypertension Yes    No    (I10 or 409.1)

Do you have or have you ever had Pulmonary Hypertension Yes    No    (I27.0 or 416.0)

Do you have a history of Myocarditis Yes    No    (I41,I40.8 or 422.0-422.99)
If Yes, provide Date: 

Do you have a history of Irregular Heartbeat Yes    No    (I49.9 or 427.9)

Do you have a history of Congestive Heart Failure (CHF)?   Yes    No    (I50.9 or 428.0)

Have you ever been told you have a Weak Heart, Cardiac Failure, or Myocardial Failure (CHF)?   Yes    No    (I50.9 or 428.9)
If Yes, provide Date: 

Do you have Chronic Renal Failure Yes    No    (??? or 585)

Do you have Renal Failure Unspecified Yes    No    (N19 or 586)

Have you ever been diagnosed with Asthma, what type? 
Extrinsic Asthma (Hay fever w/Asthma, Childhood Asthma)?   Yes    No    (I45.20 or 493.00)
Intrinsic Asthma (Late Onset Asthma)?   Yes    No    (I45.20 or 493.10)
Chronic Obstructive Asthma (Asthma w/COPD)?   Yes    No    (I44.9 or 493.20)
Asthma (Allergic Bronchitis or Asthmatic)?   Yes    No    (J45.909,J45.998 or 493.90)
Asthma Status Asthmaticus Yes    No    (J45.902 or 493.91)