Long Island Medical Care Services

Personal Medical History

Please fill out the following information if you are a new patient or if your information has changed:
Use TAB or your MOUSE to move between fields
- ENTER will submit your information

Patient information:

Full Name Date of birth
Phone number: 
Allergies
Medications
Smoker
Cigarettes   
Cigars       
Pipe         		Number per day 
Number of years
Alcohol oz per day 
Coffee/Tea cups per day   Marital Status Single           Married
Divorced      Widowed
Occupation    

 

Recent and Past Hospitalizations and Operations
Please comment on your family medical history.   State if any of your family members have had hypertension, heart disease, any form of cancer, diabetes, etc.
Use the box below to clarify your answer and state the cause of death of your parents or siblings (if appropriate).
Please check the boxes of any of the listed conditions that you may have or had and use the comment box on the right to list any complications, procedures, operations or medications associated with these conditions
Diabetes Mellitus     
Thyroid Problems
Pituitary Problems
Elevated Cholesterol
Elevated Homocysteine Level
Hypertension
Gout
Atrial Fibrillation
Irregular Heart Beat
Heart Murmur or Mitral Valve Prolapse
Angina Pectoris
Heart Attack
Angioplasty and/or stent placement
Coronary Artery Bypass
Valve Replacement
Heart Transplant
Ulcers
Esophagitis
Hiatal Hernia
Hepatitis or Other Liver Disease
Diverticulosis
Colitus
Cancer
Hemorrhoids
Hernias
Colon Polyps
Stroke
Transient Ischemic Attack
Carotid Artery Disease
Multiple Sclerosis
Seizures
Loss of conciousness
Muscle or Nerve Disease
Sciatica
Pinched Nerves
Carpal Tunnel Disease
Migraines or other headaches
Dizziness or Labyrinthitis
Lyme Disease
Osteoarthritis
Rheumatoid Arthritis
Back Problems
Raynauds Disease
Lupus
Kidney Stones
Kidney Disease
Prostate Problems
Frequent Urinary Infections
Cancer
Blood in the Urine
Bladder Problems
Glaucoma
Cataracts
Retinal Hemorrhage
Pneumonia
Chronic Bronchitis
Tuberculosis
Sarcoidosis
Emphysema
Asthma
Chronic Sinusitis
Environmental Allergies
Cancer
Blood or Bleeding Problems
Anemia
Varicose Veins or Phlebitis
Depression or Anxiety Problems
Addiction Problems
HIV
Skin Problems
FEMALES  ONLY
Ovarian Cysts
Endometriosis
Uterine Fibroids
Number of Pregnancies Number of C-Section Deliveries
Number of Vaginal Deliveries
Last Complete Physical
Last Mammogram (females only)
Last Colonoscopy
Last Prostate Exam or PSA (males only)
   
 
PATIENT SIGNATURE: ___________________________________      

When you come in to the office, this information will be printed for you to sign.
You may also be required to fill out additional paperwork, depending on
your insurance company.

 

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Last revised: January 15, 2007