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DUBUQUE INTERNAL MEDICINE
CURRENT HISTORY SHEET

Please take a few moments to fill out the following questionnaire. We will use this information as part of
our continual efforts to provide you with the best health care. All the information you provide will
become part of your medical record and is therefore kept strictly confidential. Please answer these
questions to the best of your ability, leaving blank those questions for which you are unsure of the answer.

NAME______________ _____	DATE OF BIRTH______________
HOME PHONE (___ )___ -______	WORK PHONE (___ )___ -_______
TODAY’S DATE _____________

REASON FOR VISIT
__Follow-up visit of a problem my doctor already knows about
__ New problem
__ Consultation at the request of another physician
Name of physician who sent you to Dubuque Internal Medicine
________________
__ Other

MEDICAL HISTORY:

MEDICATIONS (Please make a habit of bringing all your medicines including non-prescription
medicines and vitamin/mineral/herbal supplements to every visit to the office.)

Name of medicine	Strength (mg)/frequency	Name of medicine	Strength(mg)/frequency

ALLERGIES/ ADVERSE REACTIONS (Please list any medications to which you have had an allergic reaction. Include medications you have taken that have adverse side effects. List any foods or other
products you are allergic to as well.) If you have answered this question on a different form today,
please skip this question.

Name of medication, food or product	Type of reaction (signs or symptoms)

PAGE 2: CURRENT HISTORY SHEET

Your name___________________ Date of Birth___________ Today’s date________

SYSTEM REVIEW (Please indicate whether you have experienced any of the following symptoms
over the last several months. When more than one symptom is listed, circle the symptom that applies
to you.)

1. Constitutional symptoms such as fever, significant weight loss or weight gain, night sweats.........................................................	Yes ----	No ----
2. Eye symptoms including double vision, blurred vision, cataracts or glaucoma.......................................................................................	----	----
3. Ears, Nose, Mouth and Throat such as ringing in ears, decreased hearing, hoarseness, sinus problems, mouth sores......	----	----
4. Heart and blood vessels including chest pain, soreness in calves after walking, irregular heart beat, trouble with a heart valve, shortness of breath at night, abnormal swelling in legs........	----	----
5. Lungs such as shortness of breath, cough, wheezing................	----	----
6. Gastrointestinal symptoms like severe heartburn, difficulty swallowing, nausea, vomiting, change in bowel habits, blood in stools, stomach pain...........................................................................	----	----
7. Urinary symptoms including difficulty starting urinary stream, pain or burning when urinating...........................................................	----	----
8. Joints and muscles including pain, stiffness or swelling in a joint or muscle............................................................................................	----	----
9. Skin including a rash, sore or a change in appearance of a mole.......................................................................................................	----	----
10. Breast lump or nipple discharge, change in skin overlying breast....................................................................................................	----	----
11. Neurologic symptoms including numbness or weakness on one side of the body, slurred speech, dizziness or fainting spells	----	----
12. Psychiatric symptoms including depressed mood, anxiety, hallucinations, emotional abuse, physical abuse, sexual abuse.....	----	----
13. Hormonal related symptoms including increased thirst, increased frequency of urination, cold or heat intolerance, impotence, hot flashes, abnormal hair growth....................................	----	----
14. Blood/lymphatic system problems including abnormal bruising or bleeding, enlargement of a lymph node (unusual lump in neck, armpit or groin).....................................................................................	----	----
15. Allergic/ Immune system problems such as hives or hay fever......................................................................................................	----	----