Patient Visit

Patient Information

First Name:

Middle Initial:

Last Name:

Date of Birth:

Phone Number:

Street Address

City

State

Zipcode

Emergency Contact Information

First Name:

Last Name:

Phone Number:

Visit Information

Time of visit:

Reason for visit

Measurements

BMI

Weight: lbs

Height:

ft.

in.

Blood Pressure

Systolic mmHg

Diastolic mmHg

Blood Type

Heart Rate bpm

Temperature °F

Symptoms

Patient feels...

Pain:

Chills:

Fever:

Paresthesia:

Light-headed:

Dizzy:

Dry mouth:

Nausea:

Sick:

Short of breath:

Sleepy:

Sweaty:

Thirsty:

Tired:

Weak:

Patient Can't...

Breathe normally:

Hear normally:

Move a limb:

Pass a bowel action normally:

Pass urine normally:

Remember normally:

See properly:

Sleep normally:

Smell things normally:

Speak normally:

Stop passing watery bowel movements:

Stop scratching:

Stop sweating:

Swallow normally:

Taste properly:

Walk normally:

Write normally:

Other symptoms: List other symptoms:

Family History

History of Disease or Illness

22q11.2 deletion syndrome:

Angelman syndrome:

Canavan disease:

Charcot-Marie-Tooth disease:

Color blindness:

Cri du chat:

Cystic fibrosis:

Down syndrome:

Duchenne muscular dystrophy:

Familial Hypercholesterolemia:

Haemochromatosis:

Haemophilia:

Klinefelter syndrome:

Neurofibromatosis:

Phenylketonuria:

Polycystic kidney disease:

Prader-Willi syndrome:

Sickle-cell disease:

Spinal muscular atrophy:

Tay-Sachs disease:

Turner syndrome:

Other Illnesses or diseases: List other Illnesses and diseases:

History of cancer

Brain cancer:

Breast cancer:

Prostate cancer:

Basal cell cancer:

Melanoma:

Colon cancer:

Lung cancer:

Leukemia:

Lymphoma:

Other cancers: List other cancers:

Medical History

Current Medications
Prescription, Over-the-counter

Other Substances taken in last 30 days
Non-prescription drugs, alcohol

Travelled in the last 6 months:

What countries were visited: