RUPINDER K. MANN, M.D. 72-047 Dinah Shore, Ste. C4 Rancho Mirage, CA 92270 Phone 760-7707600 Fax 760-770-0500
Name:
Date:
Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is a shorter update form you can use. Please fill in all five pages. If you cannot remember specific details, please provide your best guess. If you are uncomfortable with any question, do not answer it. Thank you!
Main reason for today’s visit:
Other concerns:
What are your health goals for the next year?:
Where were you getting your care before?:
In the past 2 weeks, have you been bothered by:
Little interest or pleasure in doing things? Feeling down, depressed or hopeless?
YesNo YesNo
REVIEW OF SYMPTOMS: Please mark the box persistent symptoms you have had in the past few months. Read through every section and check “no problems” if none of the symptoms apply to you. List other concerns above.
General YesNo - Unexplained weight loss / gain YesNo - Unexplained fatigue / weakness YesNo - Fall asleep during day when sitting YesNo - Fever, chills YesNo - No problems
Respiratory YesNo - Cough / wheeze YesNo - Loud snoring / altered breathing during sleep YesNo - Short of breath with exertion YesNo - No problems
Hematologic/Lymphatic YesNo - Swollen glands YesNo - Easy bruising YesNo - No problems
Skin YesNo - New or change in mole YesNo - Rash / itching YesNo - No problems
Gastrointestinal YesNo - Heartburn / reflux / indigestion YesNo - Blood or change in bowel movement YesNo - Constipation YesNo - No problems
Neurological/Lymphatic YesNo - Headache YesNo - Memory loss YesNo - Fainting YesNo - Dizziness YesNo - Numbness / tingling YesNo - Unsteady gait YesNo - Frequent falls YesNo - No problems
Breast YesNo - Breast lump / pain / nipple discharge YesNo - No problems
Genitourinary YesNo - Leaking urine YesNo - Blood in urine YesNo - Nighttime urination or increased frequency YesNo - Discharge: penis or vagina YesNo - Concern with sexual function YesNo - No problems
Allergic/Immune YesNo - Hay fever / allergies YesNo - Frequent infections YesNo - No problems
Ears/Nose/Throat YesNo - Nosebleeds, trouble swallowing YesNo - Frequent sore throat, hoarseness YesNo - Hearing loss / ringing in ears YesNo - No problems
Musculoskeletal YesNo - Neck pain YesNo - Back pain YesNo - Muscle / joint pain YesNo - No problems
Psychiatric YesNo - Anxiety / stress / irritability YesNo - Sleep problem YesNo - Lack of concentration YesNo - No problems
Eyes YesNo - Change in vision / eye pain / redness YesNo - No problems
Endocrine YesNo - Heat or cold sensitivity YesNo - No problems
Women only YesNo - Pre-menstrual symptoms (bloating cramps, irritability) YesNo - Problem with menstrual periods YesNo - Hot flashes / night sweats YesNo - No problems
Cardiovascular YesNo - Chest pain / discomfort YesNo - Palpitations (fast or irregular heartbeat) YesNo - No problems
IMMUNIZATIONS: Check off any vaccinations you have had. Add year, if known. Check the box if you don’t know the information No
Tetanus (Td)With Pertussis (Tdap)Prevnar20Prevnar13Pneumococcal 23RSV-respiratory syncytial viruInfluenza (flu shot)Hepatitis AHepatitis BMMRMeningitisZostavax (shingles)Shingrix 2 PartsHPVCOVID
Tetanus (Td)
With Pertussis (Tdap)
Prevnar20
Prevnar13
Pneumococcal 23
RSV-respiratory syncytial viru
Influenza (flu shot)
Hepatitis A
Hepatitis B
MMR
Meningitis
Zostavax (shingles)
Shingrix 2 Parts
HPV
COVID
MEDICATIONS: Please list (or show us your own printed record) all prescriptions and non-prescription medications, vitamins, home remedies, birth control pills, herbs, inhalers, etc.
No Medications
Medication
Dose (e.g. mg/pill)
How many times per day?
Allergies or intolerance to medications (include type of reaction):
NONE
Lipid (cholesterol)
Cologuard/Fecal Immuneglobulin/Colonoscopy
Women only:
Mammogram
Pap Smear
Bone Density Test
Last Vision Exam
Last Dental Exam
Last Hearing Exam
Last Colonoscopy Exam
Name of Provider Who provided the exam
Next Colonscopy scheduled date
Who they live with
Boarding Care FacilitiesResidenceOther