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Medical History Checklist

This document contains a health history checklist that includes sections on past medical history, medications, and review of systems. The past medical history section lists common respiratory, neurological, hematological, cardiovascular, gastrointestinal, and other medical conditions. The medications section lists the patient's current medications, dosages, classifications, and potential dental implications. Finally, the review of systems section checks for symptoms involving general health as well as many body systems such as head/eyes/ears/nose/throat, cardiac, respiratory, gastrointestinal, musculoskeletal, neurological, and others.

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Christopher Lane
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119 views

Medical History Checklist

This document contains a health history checklist that includes sections on past medical history, medications, and review of systems. The past medical history section lists common respiratory, neurological, hematological, cardiovascular, gastrointestinal, and other medical conditions. The medications section lists the patient's current medications, dosages, classifications, and potential dental implications. Finally, the review of systems section checks for symptoms involving general health as well as many body systems such as head/eyes/ears/nose/throat, cardiac, respiratory, gastrointestinal, musculoskeletal, neurological, and others.

Uploaded by

Christopher Lane
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HEALTH HISTORY CHECKLIST

PAST MEDICAL HISTORY


Respiratory Problems (“breathing problems”) Neurologic Problems
 Asthma  Cerebrovascular Accident (“Stroke”)
 Tuberculosis  Transient Ischemic Attack – TIA (“mini stroke”)
 Sleep apnea  Multiple sclerosis
 Bronchitis/Emphysema/COPD  Epilepsy/Seizure disorder
Additional info:  Neuropathy/Neuropathic pain (“nerve pain”)
Additional info:
Hematologic Problems (“blood problems”
 Anemia Endocrine Problems
 Sickle cell disease/trait  Diabetes (“sugar diabetes”)
 HIV disease/AIDS  Thyroid disorder
 Bleeding disorders (“blood too thick or too thin”) Additional info:
 Leukemia/lymphoma (“blood cancer”)
 Coumadin/warfarin treatment (blood thinners) Other Problems
Additional info:  Renal/Kidney disease
 Dialysis
Cardiovascular Problems  Organ transplant
 Hypertension (“high blood pressure”)  Cancer
 Angina (“chest pain”)  Radiation/Chemotherapy treatment
 Myocardial infarction (“heart attack”)  Arthritis
 Prosthetic cardiac valve (“artificial heart valve”)  Artificial joint (“joint replacement”)
 Congestive heart failure  Use/used a bisphosphonate medication for osteoporosis or bone
 Coronary Artery Bypass Surgery - CABG (“heart bypass surgery”) cancer treatment
 Cardiac stent surgery Additional info:
 Pacemaker/Defibrillator
 Infective endocarditis (“heart infection”) MEDICATIONS
Additional info: Name/Dosage Classification Dental Implications

Gastrointestinal Problems
 Hepatitis/Jaundice
 Liver disease
 Gastroesophageal Reflux Disease (“reflux”)
 Ulcers
Additional info:
HEALTH HISTORY CHECKLIST

REVIEW OF SYSTEMS Gastrointestinal


 Nausea/Vomiting
General:  Diarrhea/Constipation
 Weight loss/gain  Heart burn
 Fatigue
 Fever/chills Musculoskeletal
 Insomnia  Myalgia (“Muscle pain”)
 Arthralgia (“Joint pain”)
HEENT  Stiffness
 Tinnitus (“ringing in ears”)
 Ear pain Neurologic
 Rhinorrhea (“runny nose”)  Dizziness
 Epistaxis (“nose bleeds”)  Syncope (“Fainting”)
 Mouth sores  Weakness
 Headache  Numbness/tingling
 Blurry vision/Double vision  Tremor
 Vision changes
 Numbness/Tingling of face Hematologic
 Dysphagia (“difficulty swallowing”)  Fatigue
 Bruising
Cardiac  Infections
 Chest pain  Lymphadenopathy (“swollen glands”)
 Heart palpitations
 Exercise intolerance Endocrine
 Claudication (“leg cramps/pain”)  Heat/cold intolerance
 Diaphoresis (“Sweating”)
Respiratory  Polyuria (“Frequent urination”)
 Cough  Polydipsia (“Thirst”)
 Dyspnea (“shortness of breath”)  Polyphagia (“increase in appetite”)
 Wheezing
Psychiatric
 Nervousness
 Stress
 Sadness/depression

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