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SCREENINGS -- List the most recent date and doctor for the following screenings.

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Full panel of lab work

Cholesterol (lipid) screening

Chest X-ray

Treadmill stress test

Other heart tests

Colonoscopy

Mammogram

Bone Density

Pap Smear

Date

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Doctor/Practice or Facility Name

2

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Please check any existing medical problems:

Choose One

High Blood Pressure

diabetes

Diabetes

cholesterol

Cholesterol Problems

Reflux

Reflux/Heartburn

Stroke

Stroke

Anemia

Anemia

Heart Disease please check if it applies:

Heart Disease: Please check all that applies:

Valve

Valve

Coronary

Coronary

Artery or Irregular Rhythm

Artery or Irregular Rhythm

Osteoarthritis

Osteoarthritis

Osteoporosis

Osteoporosis

Menopause

Menopause

Cancer: Fill out Type

Allergies

Allergies

Sinus Disease

Sinus Disease

Psoriasis

Psoriasis

Rheumatoid Arthritis

Rheumatoid Arthritis

Hypothyroidism

Hypothyroidism

Liver Disease

Liver Disease

Kidney Disease

Kidney Disease

Migraines

Migraines

Headaches
Headaches

Diverticulosis
Diverticulosis

Seizures

Seizures

Irritable Bowel Syndrome

Irritable bowel Syndrome

COPD/Asthma

COPD/Asthma

Depression

Depression

Anxiety

Anxiety

Bipolar

Bipolar

Eczema

Eczema

ROS-Please check any symptoms you have or have had recently:

Significant Weight Loss/Gain

Significant Weight Loss/Gain

Headache
Headaches

Sinus Drainage

Sinus Drainage

Shortness of Breath

Shortness of Breath

Vomiting

Vomiting

Painful Urination

Painful Urination

Loss of Balance

Loss of Balance

Depression

Depression

fever/Chills

Fever/Chills

Blurred Vision
Blurred Vision

Sore Throat
Sore Throat

Cough/Sputum
Cough/Sputum

Constipation
Constipation

Blood in urine
Blood in Urine

Dizziness
Dizziness

Anxiety

Anxiety

Night Sweats

Night Sweats

Glasses/Contacts
Glasses/Contacts

Hoarseness
Hoarseness

Wheezing
Wheezing

Diarrhea
Diarrhea

Difficulty Voiding
Difficulty Voiding

Blackouts
Blackouts

Tremor
Tremor

Excessive Fatigue

Excessive Fatigue

Double Vision
Double Vision

Chest Pain
Chest Pain

Severe Heartburn
Severe Heartburn

Bloody Stools
Bloody Stools

Breast Changes/Discharge
Breast Changes/Discharge

Seizure

Seizures

Rashes/Mole Changes

Rashes/Mole Changes

Insomnia

Insomnia

Ringing in Ears
Ringing in Ears

Palpitations
Palpitations

Difficulty Swallowing
Difficulty Swallowing

Black Stools
Black Stools

Menstrual changes
Menstrual Changes

Prolonged Numbness
Prolonged Numbness

Joint Pains/Swelling
Joint Pains/Swelling

Loss of Appetite

Loss of Appetite

Hearing Loss
Hearing Loss

Leg Swelling
Leg Swelling

Nausea
Nausea

Abdominal Pain
Abdominal Pain

Hot Flashes
Hot Flashes

Sexual Problems
Sexual Problems

Easy bruising
Easy Bruising

Next: Consent for Treatment

Location

10806 Reisterstown Rd, Ste 1F
Owings Mills, MD 21117

Make an Appointment

We operate by Appointments Only

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Open Hours

Tuesday – Friday: 8:30am – 6pm
Monday & Saturday: 10am – 4pm

Call Us

410-204-2866

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