KEVIN TEAL M.D., P.C.

New Patient History Data

Name Date

Main Concern: DOB Age

HISTORY OF PRESENT ILLNESS: TIMING (SPECIFIC TIME): DURATION:

LOCATION (WHERE IS THE PAIN/PROBLEM): ASSOCIATION SIGNS/SYPTOMS: CONTEXT (WHERE WERE YOU AT ONSET OF

PAIN):

SEVERITY (SCALE OF 1-10): QUALITY (NORMAL VERSUS ABNORMAL): MODIFIYING FACTORS:

PAST MEDICAL HISTORY HAVE YOU EVER HAD ONE OF THE FOLLOWING: (MARK X)

Measles Anemia Back Trouble

Mumps Bladder Infection High Blood Pressure

Chickenpox Epilepsy Low Blood Pressure

Whooping Cough Migraine Headaches Hemorrhoids

Scarlet Fever Tuberculosis Date of last chest x-ray:

Diphtheria Diabetes Asthma

Smallpox Cancer Hives or Eczema

Pneumonia Polio AIDS or HIV +

Pneumatic Fever Glaucoma Infectious Mono

Heart Disease Hernia Bronchitis

Arthritis Blood or Plasma Mitral Valve Prolapsed

Venereal Disease Transfusions Stroke

Hepatitis Thyroid Disease Any other disease, please list:

Ulcer Bleeding Tendency

Kidney Disease

PREVIOUS HOSPITALIZATIONS/SURGERIES/SERIOUS ILLNESS WHEN? HOSPITAL, CITY, STATE

MEDICATIONS (INCLUDE NONPRESCRIPTION)

Have you ever taken Phen-Fen/Redux? Yes No

PATIENT SOCIAL HISTORY

Marital Status: Single Married Separated Divorced Widowed

Use of Alcohol: Never Rarely Moderate Daily

Use of Tobacco: Never Previously, but quit: Current packs/daily:

Use of Drugs: Never Type/Frequency:

Excessive exposure at home/work: Fumes Dust Solvents Particles Noise

FAMILY MEDICAL HISTORY

Age Disease If Diseased, cause of death

Father

Mother

Sibling

Spouse

Children

REVIEW OF SYSTEMS: PLEASE INDICATE BY MARKING X ON ANY PERSONAL HISTORY BELOW:

CONSTITUTIONAL SYMPTOMS GENITOURINARY PSYCHIATRIC

Good general health lately Frequent urination Memory loss or confusion

Recent weight change Burning or painful urination Nervousness

Fever Blood in urine Depression

Fatigue Change in force of strain of urine Insomnia

Headaches Incontinence or dribbling Suicidal thoughts

EARS/NOSE/MOUTH/THROAT Kidney stones Violent or unusual thoughts

Hearing loss or ringing Sexual difficulty ENDOCRINE

Earaches or Drainage Male – testicle pain Glandular or hormone problems

Chronic sinus problems or rhinitis Female – pain with periods Excessive thirst or urination

Nose bleeds Female – irregular periods Heat or Cold intolerance

Mouth sores Female – vaginal discharge Skin becoming drier

Bleeding gums Female - # of pregnancies Change in hat or glove size

Bad breath or bad taste Female - # of miscarriages HEMATOLOGIC/LYMPHATIC

Sore throat or voice change Female – date of last pap smear: Slow to heal after cuts

Swollen glands in neck MUSCULOSKELETAL Bleeding or bruising tendency

CARDIOVASCULAR Joint pain Anemia

Heart trouble Joint stiffness or swelling Phlebitis

Chest pain or angina pectoris Weakness of muscle or joints Past transfusion

Palpitation Muscle pain or Cramps Enlarged glands

Shortness of breath w/walking or lying flat

Back Pain ALLERGIC/IMMUNOLOGIC

Swelling of feet, ankles or hands Cold extremities History of skin reaction or other adverse reaction to:

RESPIRATORY Difficulty in walking Penicillin or other antibiotics

Persistent cough or throat clearing not associated w/ a known illness (Lasting more than 3 weeks):

INTEGUMENTARY (SKIN OR BREAST)

Morphine, Demerol or other narcotics

Spitting up blood Rash or itching Novocain or other anesthetic

Shortness of breath Change in skin color Aspirin or other pain remedies

Wheezing Change in hair or nails Tetanus antitoxin or other serums

GASTRO INTESTINAL Varicose veins Iodine, Merthiolate or other antiseptic

Loss of appetite Breast pain Other drugs/meds:

Change in bowel movements Breast lump

Nausea or vomiting Breast discharge

Frequent diarrhea NEUROLOGICAL Known food allergies:

Painful bowel movements or constipation

Frequent or recurring headaches

Rectal bleeding or blood in stool Light headed or dizzy

Abdominal pain Convulsion or seizures Environmental allergies:

EYES Numbness or tingling sensation

Eye disease or injury Tremors

Wear glasses or contact lenses Paralysis

Blurred or Double vision Head injury

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need. Signature of Parent or Guardian Date Doctor’s Signature after review Date