Southwest Internal Medicine is now offering Telemedicine Services. Please contact our office for more details.

Patient History

    Patient History Update Form

    Patient Name:

    Date of birth:

    Please fill out the following queries to the best of your knowledge. If you do not know the name of the specialist you see, please write the name of their practice if you know it.

    Who is your eye doctor?

    When was your last eye examen:

    Who is your gastroenterologist(GI)?

    Name:

    When was your last colonoscopy

    Who is your gynecologist (if is applicable)?

    When was your last PAP smear:

    When was your last mammogram:

    Please list any other specialist you see that were not mentioned above:

    Speciality

    Name

    Phone number

    Speciality

    Name

    Phone number

    Speciality

    Name

    Phone number

    Speciality

    Name

    Phone number

    Since your last visit, have you had any new surgeries, procedures, or have you started seeing a new specialist?
    Please be descriptive and provide dates if applicable

    HandednessLR

    Present Concerns:

    Past Medical History

    Have you ever had:

    Chicken PoxNoYes

    HepatitisNoYes

    Scarlet FeverNoYes

    TuberculosisNoYes

    Rheumatic FeverNoYes

    PneumoniasNoYes

    PolioNoYes

    Venereal DiseaseNoYes

    Blood TransfusionsNoYes

    Have you ever been treated for:

    AsthmaNoYes

    Thyroid DiseaseNoYes

    EmphysemaNoYes

    DiabetesNoYes

    Heart AttackNoYes

    AnemiaNoYes

    Heart FailureNoYes

    CancerNoYes

    Heart MurmurNoYes

    Kidney DiseaseNoYes

    Abnormal HeartbeatNoYes

    Kidney StoneNoYes

    High Blood PressureNoYes

    Ulcer DiseaseNoYes

    ColitisNoYes

    Gall Bladder DiseaseNoYes

    Blood ClotsNoYes

    ArthritisNoYes

    StrokeNoYes

    GoutNoYes

    Epilepsy(seizures)NoYes

    Abnormal CholesterolNoYes

    Psychiatric DisorderNoYes

    Chronic Allergies, GlaucomaNoYes

    Hay FeverNoYes

    Colon PolypsNoYes

    Last Colonscopy: 

    Last Stress Test: 

    List any operations that you have had (include approximate age): 

    Have you ever been treated with X-RAY therapy or radioactive drugs?NoYes

    List any medications (and dosages) you currently are taking (include over-the-counter drugs):

    List medication allergies

    Habits

    Tobacco use?NoYes

    Did you quit?NoYes

    Alcohol?NoYes

    Coffee, tea or cola?NoYes

    Do you exercise regularly?NoYes

    What kind of work do you do? 

    Any toxic exposure?NoYes

    What method of contraception do you use (if applicable)?

    Do any of your family members have or have had:

    Family History:

    Age

    Illness

    Cancernoyes

    Father:

    Heart AttacksNoYes

    Mother:

    High blood pressureNoYes

    Brothers:

    StrokesNoYes

    Sisters:

    Thyroid diseaseNoYes

    Sons:

    DiabetesNoYes

    Daughters:

    AnemiaNoYes

    Other:

    Kidney diseaseNoYes

    UlcersNoYes

    OtherNoYes

    Are you bothered with:

    Skin Rashes or DiscolorationNoYes

    Loss of Consciousness(Fainting)NoYes

    Abnormal Lumps or GlandsNoYes

    Unusual or Serious Visual ProblemsNoYes

    Nausea or VomitingNoYes

    Hearing, Problems, EarachesNoYes

    Belly PainNoYes

    HeadachesNoYes

    ConstipationNoYes

    Frequent ColdsNoYes

    DiarrheaNoYes

    HoarsenessNoYes

    Bloody or Tarry StoolsNoYes

    Frequent or Persistent CoughNoYes

    Excessive or Constant WorryingNoYes

    Feeling Lonely or DepressedNoYes

    Abnormal TirednessNoYes

    Inability to Sleep WellNoYes

    Shortness of BreathNoYes

    Mood SwingsNoYes

    WheezingNoYes

    Poor AppetiteNoYes

    Chest PainNoYes

    Difficulty SwallowingNoYes

    Skipped or Irregular HeartbeatNoYes

    HemorrhoidsNoYes

    Ankle SwellingNoYes

    Trouble UrinatingNoYes

    Pain in your Legs when you walkNoYes

    ArthritisNoYes

    Weakness in your Arms or LegsNoYes

    Morning StiffnessNoYes

    Loss of Sensation (numbness)NoYes

    Fever or ChillsNoYes

    LightheadednessNoYes

    Impotence or Other Sexual DifficultyNoYes

    Night SweatsNoYes

    BruisesNoYes

    Weight LossNoYes

    Weight GainNoYes

    Please give details of any yes answers or of other symptoms not listed above

    Please list any other doctors you currently see:

    Female Patients - Do you have any problems with:

    CrampsNoYes

    Heavy BleedingNoYes

    IrregularNoYes

    DischargeNoYes

    Painful intercourseNoYes

    Last Breast Exam/Mammogram  

    Your last menstrual period? 

    Last Pap Smear  

    Last Bone Density Scan  

    Number of pregnancies and any complications  

    Please write your signature in the box below(required)

    Date:

    Contact us

    Ph: 407-345-0005
    Fx: 888-219-6957
    info@southwestinternalmedicine.com
    Office Location
    5979 Vineland Rd. Suite 310 Orlando, FL 32819

    Scroll to Top