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Instructions: Please complete the from below. You DO NOT have to enter your name or address. This information is optional. If the patient is 13 years old or younger,please complete the Pediatric History in addition to the other information on this form. Thank you.
Patient Entry
Firstname:
Lastname:
Email:
Gmail.com
*Gender:
Male
Female
*Age:
1
2
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> 89
Phone 1:
Phone 2:
Address 1:
Address 2:
City:
State:
Country:
Zip:
*Ethnicity:
NA
Caucasian
African American
Hispanic
Asian
Other Ethnicity:
Medications:
Additional notes:
If you cannot find your diagnosis or diagnoses in the ICD-9 list then enter the name of your condition(s) in the Diagnosis field boxes below the ICD-9 fields.
Diagnosis [ICD9]
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Diagnosis [ICD9]
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Diagnosis [ICD9]
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Diagnosis [ICD9]
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Diagnosis[1]
Diagnosis[2]
Diagnosis[3]
Diagnosis[4]
Diagnosis[5]
Diagnosis[6]
Diagnosis[7]
Pediatric History
Family History
157
Birth Defects
NA
Yes
No
Father
Mother
Sibling
Other
158
Genetic Defects
NA
Yes
No
Father
Mother
Sibling
Other
159
Mental Retardation
NA
Yes
No
Father
Mother
Sibling
Other
160
Allergies
NA
Yes
No
Father
Mother
Sibling
Other
161
Lung Disease
NA
Yes
No
Father
Mother
Sibling
Other
162
Asthma
NA
Yes
No
Father
Mother
Sibling
Other
163
Bone/Joint Disorder
NA
Yes
No
Father
Mother
Sibling
Other
164
Rheumatoid Arthritis
NA
Yes
No
Father
Mother
Sibling
Other
165
Muscle Disorders
NA
Yes
No
Father
Mother
Sibling
Other
166
Skin Disease
NA
Yes
No
Father
Mother
Sibling
Other
167
Eye or Ear Disorders
NA
Yes
No
Father
Mother
Sibling
Other
168
Cancer
NA
Yes
No
Father
Mother
Sibling
Other
169
Diabetes
NA
Yes
No
Father
Mother
Sibling
Other
170
Thyroid Disease
NA
Yes
No
Father
Mother
Sibling
Other
171
Heart Disease/Problems
NA
Yes
No
Father
Mother
Sibling
Other
172
Anemia/Blood Disorders
NA
Yes
No
Father
Mother
Sibling
Other
173
High Blood Pressure
NA
Yes
No
Father
Mother
Sibling
Other
174
Kidney Disease/Problems
NA
Yes
No
Father
Mother
Sibling
Other
175
Rheumatic Fever
NA
Yes
No
Father
Mother
Sibling
Other
176
Tuberculosis
NA
Yes
No
Father
Mother
Sibling
Other
177
Seizures/Convulsions
NA
Yes
No
Father
Mother
Sibling
Other
178
MentalDisease/Disorder
NA
Yes
No
Father
Mother
Sibling
Other
179
Venereal Disease
NA
Yes
No
Father
Mother
Sibling
Other
180
HIV/AIDS
NA
Yes
No
Father
Mother
Sibling
Other
785
Other
Disease History
181
Measles (10 day)
NA
Yes
No
182
Rubella (3 day measles)
NA
Yes
No
183
Mumps
NA
Yes
No
184
Chicken Pox
NA
Yes
No
185
Whooping Cough
NA
Yes
No
186
Rheumatic Fever
NA
Yes
No
187
Hepatitis (liver disorders)
NA
Yes
No
188
Bronchitis or Chronic Cough
NA
Yes
No
189
Asthma
NA
Yes
No
190
Pneumonia
NA
Yes
No
191
Anemia/Blood Disorders
NA
Yes
No
192
Difficulty Talking
NA
Yes
No
193
Stuttering
NA
Yes
No
197
Frequent Headaches
NA
Yes
No
782
Other
Eyes
194
Crossed or Wandering
NA
Yes
No
195
Vision Problems
NA
Yes
No
196
Eye Irritation
NA
Yes
No
784
Other
Ears
198
Frequent Ear Infections
NA
Yes
No
199
Hearing Problems
NA
Yes
No
783
Other
Mouth
200
Been to dentist
NA
Yes
No
201
Date of visit
NA
Yes
No
202
Dental Problems
NA
Yes
No
203
Sores in Mouth/Gums
NA
Yes
No
789
Other
Nose and Throat
204
Frequent Sore Throats
NA
Yes
No
205
Persistant Hoarseness
NA
Yes
No
206
Frequent Nose Bleeds
NA
Yes
No
207
Frequent Stuffed Up Nose
NA
Yes
No
208
Frequent Tonsil Infections
NA
Yes
No
792
Other
Heart and Lungs
209
Mouth Breathing
NA
Yes
No
210
Difficulty Breathing
NA
Yes
No
211
Tendency to Wheeze
NA
Yes
No
212
Repeated Coughing Spells
NA
Yes
No
213
Shortness of Breath
NA
Yes
No
214
Propped up in Bed
NA
Yes
No
216
To Squat Down to Breath
NA
Yes
No
788
Other
Nevrous System
218
Dizzy or Fainting Spells
NA
Yes
No
219
Periods of confusion or
NA
Yes
No
220
Disorientation Convulsions, Seizures
NA
Yes
No
222
Tremors (the shakes)
NA
Yes
No
223
Difficulty Walking, Balancing or handling Objects
NA
Yes
No
791
Other
Skin
225
Eczema/Skin Problems
NA
Yes
No
226
Slow Healing Bruises
NA
Yes
No
227
Persistent Rashes
NA
Yes
No
795
Other
Digestive System
228
Frequent Stomach Aches
NA
Yes
No
229
Frequent Diarrhea
NA
Yes
No
230
Frequent Constipation
NA
Yes
No
231
Frequent Nausea or vomiting
NA
Yes
No
232
Worms
NA
Yes
No
233
Bloody or Very Dark Stools
NA
Yes
No
234
Special Food Restrictions
NA
Yes
No
781
Other
Genitourinary System
235
A Urination Problem
NA
Yes
No
236
Painful Burning Urination
NA
Yes
No
237
Blood in Urine
NA
Yes
No
238
Unusual Urine Odor
NA
Yes
No
239
Persistant Diaper Rash
NA
Yes
No
240
Bed Wetting Problems
NA
Yes
No
241
Penis/Vagina Discharge
NA
Yes
No
787
Others
General
242
Excessive Thirst
NA
Yes
No
243
Increase/Decrease Appetite
NA
Yes
No
244
Unusual Heat/Cold Sensitivity
NA
Yes
No
245
Eaten Paint, Dirt, or Plaster
NA
Yes
No
246
Persistantly Tired
NA
Yes
No
247
Unusual Slow Healing Wounds
NA
Yes
No
248
Recurrent Fever
NA
Yes
No
786
Other
Past Six Months
249
Had Frequent Nightmares
NA
Yes
No
250
Been Unusually Nervous or High Strung
NA
Yes
No
251
Had Extreme Mood Swings
NA
Yes
No
252
Been Unusually Disobedient
NA
Yes
No
253
Been Having Problems with Friends
NA
Yes
No
254
Been Having Problems at School
NA
Yes
No
793
Other
Preqnancy History
255
Prenatal Care
NA
Yes
No
256
High Blood Pressure
NA
Yes
No
257
Gestational Diabetes
NA
Yes
No
258
Venereal Disease
NA
Yes
No
259
German (3 Day) Measles
NA
Yes
No
260
Exposure to Known Cause of Birth Defects
NA
Yes
No
261
Any Illness,Infection, or High Fever
NA
Yes
No
794
Other
Past Medical History
Neurological History
538
Brain Injury With LOC
NA
Patient
Family
539
Brain Injury Without LOC
NA
Patient
Family
540
Cerebellum Dysfunction
NA
Patient
Family
541
Cognitive Disorder
NA
Patient
Family
542
CVA (Stroke)
NA
Patient
Family
543
Dementia
NA
Patient
Family
544
Hemiparesis L or R
NA
Patient
Family
545
Hemiplegia Lor R
NA
Patient
Family
546
Migraines
NA
Patient
Family
547
Multiple Sclerosis
NA
Patient
Family
548
Neuropathy
NA
Patient
Family
549
Parkinsons Disease
NA
Patient
Family
550
Seizures
NA
Patient
Family
551
TIAs
NA
Patient
Family
765
Others
Psychiatric History
552
Alcoholism
NA
Patient
Family
553
Anorexia
NA
Patient
Family
554
Anxiety
NA
Patient
Family
555
Anxiety with Panic Disorder
NA
Patient
Family
556
Bulimia
NA
Patient
Family
557
Bipolar Disorder
NA
Patient
Family
558
Depression
NA
Patient
Family
559
Dysthymia
NA
Patient
Family
560
OCD
NA
Patient
Family
561
Personality Disorder
NA
Patient
Family
562
Phobias
NA
Patient
Family
563
Psychosis (brief)
NA
Patient
Family
564
Psychosis unspecified
NA
Patient
Family
565
Schizoaffective Disorder
NA
Patient
Family
566
Schizophrenia
NA
Patient
Family
567
Somatization Disorder
NA
Patient
Family
568
Suicidal Behaviors
NA
Patient
Family
569
Substance Abuse
NA
Patient
Family
768
Others
Cancer History
570
Cancer
NA
Patient
Family
571
Breast Carcinoma
NA
Patient
Family
572
Colon Carcinoma
NA
Patient
Family
573
Hodgkins Disease
NA
Patient
Family
574
Liver Carcinoma
NA
Patient
Family
575
Lung Carcinoma
NA
Patient
Family
576
Melanoma
NA
Patient
Family
577
Ovarian Carcinoma
NA
Patient
Family
578
Pancreatic Carcinoma
NA
Patient
Family
579
Prostate Carcinoma
NA
Patient
Family
763
Others
Gl Disorders
580
Crohns Disease
NA
Patient
Family
581
Colitis
NA
Patient
Family
582
Constipation
NA
Patient
Family
583
Diarrhea
NA
Patient
Family
584
Diverticulosis
NA
Patient
Family
585
Diverticulitis
NA
Patient
Family
586
Dysphagia
NA
Patient
Family
587
Fecal Impaction
NA
Patient
Family
588
Gastritis
NA
Patient
Family
589
Gl Bleeding
NA
Patient
Family
590
Hemorrhoids
NA
Patient
Family
591
Hiatus Hernia
NA
Patient
Family
592
IBS
NA
Patient
Family
593
Pancreatitis Acute
NA
Patient
Family
594
Pancreatitis Chronic
NA
Patient
Family
759
Others
Cardiac
595
Angina Pectoris
NA
Patient
Family
596
Arrhythmia
NA
Patient
Family
597
ASHD
NA
Patient
Family
598
Atrial Fibrillation
NA
Patient
Family
599
Coronary Artery Disease
NA
Patient
Family
600
Cardiac Arrest
NA
Patient
Family
601
Cardiomyopathy
NA
Patient
Family
602
Hypertension
NA
Patient
Family
603
Orthostatic Hypotension
NA
Patient
Family
604
Congestive Heart Failure
NA
Patient
Family
605
Peripheral Vascular Disease
NA
Patient
Family
606
Bradycardia
NA
Patient
Family
607
Ml
NA
Patient
Family
608
Syncope
NA
Patient
Family
609
Tachycardia
NA
Patient
Family
756
Others
Dermatologic
610
Alopecia
NA
Patient
Family
611
Cellulitis
NA
Patient
Family
612
Dermatitis
NA
Patient
Family
613
Pressure Sores
NA
Patient
Family
614
Psoriasis
NA
Patient
Family
757
Others
ENT Disorders
615
Earache
NA
Patient
Family
616
External Otitis
NA
Patient
Family
617
Hearing Loss
NA
Patient
Family
618
Herpes Zoster Oticus
NA
Patient
Family
619
Labyrinthitis
NA
Patient
Family
620
Laryngitis
NA
Patient
Family
621
Mastoiditis
NA
Patient
Family
622
Menieres Disease
NA
Patient
Family
623
Nasal Polyps
NA
Patient
Family
624
Otitis Media
NA
Patient
Family
625
Otosclerosis
NA
Patient
Family
626
Positional Vertigo
NA
Patient
Family
627
Rhinitis
NA
Patient
Family
628
Sinusitis
NA
Patient
Family
629
Vocal Cord Paralysis
NA
Patient
Family
758
Others
Hepatic and Bilary
630
Cholecystitis
NA
Patient
Family
631
Choledocholithiasis
NA
Patient
Family
632
Cirrhosis Alcohol
NA
Patient
Family
633
Fatty Liver
NA
Patient
Family
634
Hepatitis
NA
Patient
Family
752
Hepatitis A
NA
Patient
Family
753
Hepatitis B
NA
Patient
Family
754
Hepatitis C
NA
Patient
Family
635
Hepatic Granulomas
NA
Patient
Family
636
Hepatic Vascular Lesions
NA
Patient
Family
761
Others
Hematologic
637
Anemia
NA
Patient
Family
638
Blood Transfusion
NA
Patient
Family
639
Hodgkins
NA
Patient
Family
640
Leukemia Acute
NA
Patient
Family
641
Leukemia Chronic
NA
Patient
Family
642
Leukopenia
NA
Patient
Family
643
Lymphoma
NA
Patient
Family
644
Platelet Dysfunction
NA
Patient
Family
760
Others
Immunodeficiencies
645
Allergies
NA
Patient
Family
646
B Cell Deficiency
NA
Patient
Family
647
T Cell Deficiency
NA
Patient
Family
648
Combined B and T Cell
NA
Patient
Family
762
Others
Metabolic
649
Amyloidosis
NA
Patient
Family
650
Addisons Disease
NA
Patient
Family
651
Cushing Disease
NA
Patient
Family
652
Electrolyle Imbalance
NA
Patient
Family
653
Hyperlipidemia
NA
Patient
Family
654
Hypolipidemia
NA
Patient
Family
655
Hypopituitarism
NA
Patient
Family
656
Hyperpiuitarism
NA
Patient
Family
657
Hypoglycemia
NA
Patient
Family
658
Insulin Dependent Diabetes Mellitus
NA
Patient
Family
659
Non-Insulin Diabetes Mellitus
NA
Patient
Family
660
Porphyria
NA
Patient
Family
661
Renal Insufficiency
NA
Patient
Family
764
Others
Opthalmologic
662
Macular Degeneration
NA
Patient
Family
663
Glaucoma
NA
Patient
Family
664
Cateracts
NA
Patient
Family
665
Vitreous Hemorrhagic
NA
Patient
Family
666
Blindness
NA
Patient
Family
766
Others
Oral Disorders
667
Dysphagia (swallowing difficulties)
NA
Patient
Family
668
Oropharyngeal disorder
NA
Patient
Family
669
Esopharyngeal disorder
NA
Patient
Family
670
Gingivitis
NA
Patient
Family
670
Others
Pulmonary
671
Asthma
NA
Patient
Family
672
Atelectasis Acute
NA
Patient
Family
673
Atelectasis Chronic
NA
Patient
Family
674
Bronchitis Acute
NA
Patient
Family
675
Emphysema
NA
Patient
Family
676
Lung Abscess
NA
Patient
Family
677
Pleural Effusion
NA
Patient
Family
678
Pleural Fibrosis
NA
Patient
Family
679
Pneumonia
NA
Patient
Family
680
Pneumothorax
NA
Patient
Family
681
Pulmonary Embolism
NA
Patient
Family
682
Respiratory Embolism
NA
Patient
Family
683
Respiratory Failure
NA
Patient
Family
684
Upper Respiratory Infection
NA
Patient
Family
769
Others
Rheumatological
685
Gout
NA
Patient
Family
686
Osteoarthritis
NA
Patient
Family
687
Osteomyelitis
NA
Patient
Family
688
Osteoporosis
NA
Patient
Family
689
Paget Disease
NA
Patient
Family
690
Polymyalgia
NA
Patient
Family
691
Rheumatoid Arthritis
NA
Patient
Family
692
Polymyostis
NA
Patient
Family
694
Scleroderma
NA
Patient
Family
695
Systemic Lupus Erythematosus
NA
Patient
Family
696
Sjgren Syndrome
NA
Patient
Family
697
Vasculitis
NA
Patient
Family
698
Systemic Sclerosis
NA
Patient
Family
699
Temporal Arteritis
NA
Patient
Family
770
Others
Surgical
700
Aortic Valve Repl
NA
Patient
Family
701
Appendectomy
NA
Patient
Family
702
CABG
NA
Patient
Family
703
Cholecystectomy
NA
Patient
Family
704
Coloslomy
NA
Patient
Family
705
Gastroslomy
NA
Patient
Family
706
Hip Replacement
NA
Patient
Family
707
Hysterectomy
NA
Patient
Family
708
Knee Replacement
NA
Patient
Family
709
lleostomy
NA
Patient
Family
710
Intestinal Bypass
NA
Patient
Family
711
Pacemaker
NA
Patient
Family
712
Mastectomy
NA
Patient
Family
771
Others
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