SAINT LOUIS UNIVERSITY

SCHOOL OF MEDICINE
PAST MEDICAL HISTORY:
DEPARTMENT OF MEDICINE
Childhood Illnesses (if relevant): _______________________________________
GENERAL DATA:
Adult diseases: ____________________________________________________________
Name:___________________________________________________________________
Treatment: ________________________________________________________________
Address: _______________________________________________________________
Previous confinements: __________________________________________________
Age: __________ Sex: ______ Birthdate: ________________Race: ___________
Surgeries/year: ___________________________________________________________
Religion: __________ Marital Status: ________Occupation: _____________
Adult Vaccinations: _______________________________________________________
Informant: _________________________________Reliability: ____________%
Lab test/results: __________________________________________________________
Allergies: __________________________________________________________________
CHIEF COMPLAINT:

OB-GYNE HISTORY:
HISTORY OF PRESENT ILLNESS: (for all female patients):
Onset: _____________________________________________________________________ LMP: _______________________________________________________________________
Precipitating factors: _____________________________________________________ OB score: Gravida_____Parity_____
Quality: ____________________________________________________________________ Term_____Preterm_____Abortion_____ Living _____
Radiation: _________________________________________________________________ (if relevant):
Relieving factors: _________________________________________________________ Duration of menses: _____________No. of pads per day: _________________
Drug. Dosage, effect (if any): ____________________________________________ Dysmenorrhea: __________ Family Planning method: ___________________
Severity/Setting: _________________________________________________________ Papsmear: __________ Last sexual contact: _______________________________
Timing/Duration/Frequency: ___________________________________________ No. of sexual partner/s: __________ Age of menopause: _________________
Location: __________________________________________________________________
Associatedmanifestations/symptoms:_________________________________________ FAMILY HISTORY:
____________________________________________________________________________________ Heredofamilial diseases: _________________________________________________
_______________________________________________________________
Immediate family member with heredofamilial diseases: eye/ear/nose discharge ( ) hearing loss ( ) colds ( ) epistaxis ( ) gum
____________________________________________________________________________________ bleeding ( ) sore throat ( ) hoarseness ( ) goiter ( ) neck stiffness ( )
______________________________________________________________________ swollen glands
Deceased immediate family members: Breasts: ( ) lumps ( ) pain ( ) nipple discharge
_____________________________________________________________________________ Respiratory: ( ) cough ( ) sputum (color, quantity) ( ) hemoptysis ( )
Age and Cause of death: _________________________________________________ dypsnea ( ) wheezing ( ) pleurisy
Cardiovascular: ( ) chest pain ( ) palpitations ( ) dyspnea ( ) orthopnea (
PERSONAL AND SOCIAL HISTORY: ) paroxysmal nocturnal dyspnea ( ) edema
Smoking (Y/N): _______ Sticks/day: _______ Years of smoking: _________ Gastrointestinal: ( ) dysphagia ( ) heartburn ( ) anorexia ( ) vomiting ( )
Quit smoking at age or year: ______________Drinking(Y/N):_____________ constipation ( ) diarrhea ( )abdominal pain ( ) melena ( ) hematochezia (
Type of alcoholic beverage/Amount/Frequency per week: ) jaundice
_____________________________________________________________________________ Peripheral Vascular: ( ) intermittent claudication ( ) leg cramps ( )
Source of drinking water: _______________________________________________ edema ( ) varicose veins
Garbage disposal: ________________________________________________________ Genitourinary: ( ) dysuria ( ) hematuria ( ) nocturia ( ) oliguria ( )
Type of toilet: ____________________________________________________________ frequency ( ) hesitancy ( ) dribbling ( ) discharge ( ) dyspareunia
History of travel: _________________________________________________________ ( ) vaginal pruritus ( ) vaginal bleeding
Exposure to endemic diseases: _________________________________________ Musculoskeletal: ( ) muscle or joint pain ( ) stiffness, ( )weakness ( )
Dietary preference: ______________________________________________________ limitation of motion ( ) trauma
Active or sedentary ______________________________________________________ Neurologic: ( ) change in speech ( ) change in orientation ( ) weakness ( )
numbness or loss of sensation ( ) tingling or pins and needles, ( )
REVIEW OF SYSTEMS: (Choose 5 symptoms per system) seizures
General: ( ) weight change ( ) fever ( ) weakness ( ) pain Psychiatric (if relevant): ( ) nervousness ( ) tension ( ) depression ( )
Skin: ( ) rashes ( ) lumps ( ) sores ( ) itching ( ) dryness memory change ( ) suicide attempts
HEENT: ( ) headache ( ) trauma ( ) dizziness ( ) blurred vision ( ) glasses
or contact lenses ( ) eye redness ( ) diplopia ( ) cataracts ( ) tinnitus ( )