Medical History Please complete the following medical history for the patient being seen by our officeName(Required) First Last Email Address(Required) Please fill in the patients DOB(Required) MM slash DD slash YYYY Person filling out Form?(Required) Self Mom Dad Grandparent Other (Specify) Please specify who is filing out this form Please provide the patient's most recent weight in either kilograms (kg) or pounds (lb). Please identify which unit of measurement.Choose unit of measurement for weight(Required) Kilograms (kg) Pounds (lbs) Weight in kilograms Weight in pounds Please provide the patient's most recent height in either centimeters (cm) or inches (in). Please identify which unit of measurement.Choose unit of measurement for height(Required) Centimeters (cm) Inches (in) Height in centimeters Height in inches Patient and Family HistoryAre immunizations up to date?(Required) Yes No Please identify any food, drug, or environmental allergies the patient suffers from. If none please put “N/A"Please list allergic reactions to above identified allergies. If none please put “N/A"Please identity any prescribed or non-prescribed medications the patient is taking, dosage, and how many times per day. If none please put "N/A"For any prescribed prescription medications, are pills or liquid preferred? Please keep in mind that without BOTH a height and weight, medication cannot be prescribed Pill medication Liquid medication Did the patient or family have any recent illnesses or come into contact with a known COVID positive individual. If so, when?Chief Complaint/Reason for upcoming visit:What would you like to talk about or have happen during your upcoming visit?Does the PATIENT suffer from any of the following medical conditions? History of Keloiding/Abnormal scarring History of Eczema IUGR Was Testosterone given by another doctor (a shot or cream) Was he born premature (less than 37 weeks) None of the above If any of the above are positive, please explain in more detail. For testosterone please identify the details of usage and if premature please clarify weeksHistory of Present Illness Has the patient had Bladder/Kidney UTIs? Has the patient had any fever with these infections? Does the patient have pain when urinating? Have you seen blood in the patient’s urine? Has the patient had problems with constipation? Is the patient toilet trained? How often does the patient urinate during the day? Please specify how often the patient urinates during the daySurgical HistoryPlease list out the number of surgeries (if any) the above patient has had, the surgeon's name, and the dates of surgery (if known). This is to verify we have all the correct notes on file in the patient's chart.Review of SystemsHas the patient had any of the following problems? If yes, please describe. Brain Problems/ Seizures Heart Problems Breathing Problems Sleeping Problems/ Snoring Stomach Problems Bladder/ Kidney Problems Thyroid Problems Bone/ Muscle Problems Diabetes Cancer Frequent infections Bleeding Problems Other medical problems Please describe any of the issues selected aboveFamily HistoryDoes/HAS the patient's FAMILY suffer from any of the following medical conditions? Keloiding/Abnormal Scarring (If yes, who?) Prenatal Progesterone involving the patient Hypospadias/Chordee (If yes, who?) Kidney/Urologic problems? (If yes, who and what problem?) None of the above If any of the above are positive, please explain in more detail by providing the relation of the applicable family member.Hyperbaric Oxygen Treatments (HBOT)Has hyperbaric oxygen therapy (HBOT) been recommended to you? If so, please list if that has been taken care of or if you need more information. If not, please put "not recommended". HBOT has been recommended I need more information regarding HBOT HBOT has not been recommended Please identify the facility you are going to so that we can verify they have everything needed from our office. Date form Completed: MM slash DD slash YYYY Agreement(Required) By checking this box, I agree that all the above information is accurate PhoneThis field is for validation purposes and should be left unchanged. Δ
