Medical History Form

• Hospital/Clinic

• Conducted on

  Date

• Prepared by

• Location
  Address

General Information

• Name

• Birth date

  Date

• Age

• Sex

• Contact phone numbers

• Briefly describe your present symptoms

• Please list other physicians you have seen in the last 12 months, and for what reason.

Current Medications

• Drug allergies?

  Yes

  No

• To what:

• Medications that you are now taking. Include non-prescription medications & vitamins or supplements.

Medical History

• Do you now or have you ever had:

• Diabetes

  Yes

  No

• High blood pressure

  Yes

  No

• High cholesterol

  Yes

  No

• Hypothyroidism

  Yes

  No

• Goiter

  Yes

  No

• Cancer

  Yes

  No

• Type:

• Leukemia

  Yes

  No

• Psoriasis

  Yes

  No

• Psychiatric condition

  Yes

  No

• Type:

• Angina

  Yes

  No

• Heart problems

  Yes

  No

• Heart murmur

  Yes

  No

• Pneumonia

  Yes

  No

• Pulmonary embolism

  Yes

  No

• Asthma

  Yes

  No

• Emphysema

  Yes

  No

• Stroke

  Yes

  No

• Epilepsy (seizures)

  Yes

  No

• Cataracts

  Yes

  No

• Glaucoma

  Yes

  No

• Kidney disease

  Yes

  No

• Kidney stones

  Yes

  No

• Crohn’s disease

  Yes

  No

• Colitis

  Yes

  No

• Anemia

  Yes

  No

• Jaundice

  Yes

  No

• Hepatitis

  Yes

  No

• Stomach or peptic ulcer

  Yes

  No

• Varicose veins

  Yes

  No

• Environmental allergies

  Yes

  No

• Blood clots

  Yes

  No

• Serious trauma

  Yes

  No

• Sexually transmitted infection

  Yes

  No

• Other:

Personal History

• Childhood Illness

  Select Measles Mumps Rubella Chickenpox Rheumatic Fever Polio None

  • Measles
  • Mumps
  • Rubella
  • Chickenpox
  • Rheumatic Fever
  • Polio
  • None

• Immunizations?

  Yes

  No

• Tetanus

  ✔

  ✖

• Date of immunization

  Date

• Pneumonia

  ✔

  ✖

• Date of immunization

  Date

• Hepatitis A

  ✔

  ✖

• Date of immunization

  Date

• Hepatitis B

  ✔

  ✖

• Date of immunization

  Date

• Chickenpox

  ✔

  ✖

• Date of immunization

  Date

• Influenza

  ✔

  ✖

• Date of immunization

  Date

• MMR (Measles, Mumps, Rubella)

  ✔

  ✖

• Date of immunization

  Date

• Meningococcal

  ✔

  ✖

• Date of immunization

  Date

• Any surgeries?

  Yes

  No

• Please provide the year/reason/hospital

• Have you ever had a blood transfusion?

  Yes

  No

• Where were you born & raised?

• What is your highest education?

  High school

  Some college

  College graduate

  Advanced degree

• Marital status

  Select Never married Married Divorced Separated Widowed Partnered/significant other

  • Never married
  • Married
  • Divorced
  • Separated
  • Widowed
  • Partnered/significant other

• What is your current or past occupation?

Family History

• Family history is:

  Known

  Unknown

• Please indicate if your family has a history of the following: (include only parents, grandparents, siblings, and children)

• Alcohol Abuse

  Yes

  No

• Anemia

  Yes

  No

• Anesthetic Complication

  Yes

  No

• Arthritis

  Yes

  No

• Asthma

  Yes

  No

• Bladder Problems

  Yes

  No

• Bleeding Disease

  Yes

  No

• Breast Cancer

  Yes

  No

• Colon Cancer

  Yes

  No

• Depression

  Yes

  No

• Diabetes

  Yes

  No

• Heart Disease

  Yes

  No

• High Blood Pressure

  Yes

  No

• High Cholesterol

  Yes

  No

• Kidney Disease

  Yes

  No

• Leukemia

  Yes

  No

• Lung/Respiratory Disease

  Yes

  No

• Migraines

  Yes

  No

• Osteoporosis

  Yes

  No

• Other Cancer

  Yes

  No

• Rectal Cancer

  Yes

  No

• Seizures/Convulsions

  Yes

  No

• Severe Allergy

  Yes

  No

• Stroke/CVA of the Brain

  Yes

  No

• Thyroid Problems

  Yes

  No

• Mother, Grandmother, or Sister developed heart disease before the age of 65

  Yes

  No

• Father, Grandfather, or Brother developed heart disease before the age of 55

  Yes

  No

• NONE of the Above

  Yes

  No

Review of Systems

• Please indicate with a check (√) any current problems you have below.

Constitutional

• Fevers/chills/sweats

  ✔

  ✖

• Unexplained weight loss/gain

  ✔

  ✖

• Fatigue/weakness

  ✔

  ✖

• Excessive thirst or urination

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Cardiovascular

• Chest pain/discomfort

  ✔

  ✖

• Leg pain with exercise

  ✔

  ✖

• Heart murmur or heart problems

  ✔

  ✖

• Palpitations

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Chest

• Breast lump/discharge

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Ears/Nose/Throat/Mouth

• Difficulty hearing/ringing in ears

  ✔

  ✖

• Hay fever/allergies

  ✔

  ✖

• Problems with teeth/gums

  ✔

  ✖

• Difficulty swallowing

  ✔

  ✖

• Difficulty with speech

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Endocrine

• Hypothyroid

  ✔

  ✖

• Hyperthyroid

  ✔

  ✖

• Abnormal hormone levels

  ✔

  ✖

• Abnormal blood glucose levels

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Eyes

• Changes in vision

  ✔

  ✖

• Farsighted

  ✔

  ✖

• Nearsighted

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Gastrointestinal

• Abdominal pain

  ✔

  ✖

• Blood in bowel movement

  ✔

  ✖

• Nausea/vomiting/diarrhea

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Genitourinary

• Nighttime urination

  ✔

  ✖

• Incontinence

  ✔

  ✖

• Sexual function problems

  ✔

  ✖

• Discharge from penis

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Gynecological

• Abnormal vaginal bleeding

  ✔

  ✖

• Problems with conceiving

  ✔

  ✖

• Problems with contraception

  ✔

  ✖

• Vaginal discharge

  ✔

  ✖

• Vaginal odor

  ✔

  ✖

• Painful intercourse

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Lymphatic/Blood

• Unexplained lumps

  ✔

  ✖

• Easy bruising/bleeding

  ✔

  ✖

• Anemia

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Musculo-skeletal

• Muscle/joint pain

  ✔

  ✖

• Arthritis

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Neurological

• Headaches

  ✔

  ✖

• Dizziness/light-headedness

  ✔

  ✖

• Numbness

  ✔

  ✖

• Memory loss

  ✔

  ✖

• Loss of coordination

  ✔

  ✖

• Epilepsy or convulsive seizures

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Psychiatric

• Anxiety/stress

  ✔

  ✖

• Problems with sleep

  ✔

  ✖

• Depression

  ✔

  ✖

• Suicidal ideations

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Respiratory

• Cough/wheeze

  ✔

  ✖

• Difficulty breathing

  ✔

  ✖

• Asthma

  ✔

  ✖

• COPD

  ✔

  ✖

• Sleep apnea

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Skin

• Rash or mole change(s)

  ✔

  ✖

• Psoriasis

  ✔

  ✖

• Eczema

  ✔

  ✖

• Other

  ✔

  ✖

• Please describe other

Sexual History

• Have you ever been sexually active?

  Yes

  No

• Are you currently sexually active?

  Yes

  No

• Complete the following questions if you are sexually active.

• Are you currently having sexual relations with one partner or multiple partners?

  One

  Multiple

• Number of partners in last year

• Are you in a monogamous relationship?

  Yes

  No

• Are/Is your sexual partner(s)

  Men

  Women

  Both

• Do you and your partner use contraceptive and/or protective methods?

  Yes

  No

• Have you ever had a sexually transmitted illness (STI) (i.e. HPV, Herpes, Chlamydia, Gonorrhea or other)? <br>

  Yes

  No

• List STI:

• Treated

  Yes

  No

• Women's Reproductive History

• Age of first period

• Number of pregnancies

• Number of miscarriages

• Number of abortions

• Do you have regular periods?

  Yes

  No

• Have you reached menopause?

  Yes

  No

• At what age?

• Patient Name and Signature:

  Sign