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Medical History

General Information

Name

Birth 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?

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

High blood pressure

High cholesterol

Hypothyroidism

Goiter

Cancer

Type:

Leukemia

Psoriasis

Psychiatric condition

Type:

Angina

Heart problems

Heart murmur

Pneumonia

Pulmonary embolism

Asthma

Emphysema

Stroke

Epilepsy (seizures)

Cataracts

Glaucoma

Kidney disease

Kidney stones

Crohn’s disease

Colitis

Anemia

Jaundice

Hepatitis

Stomach or peptic ulcer

Varicose veins

Environmental allergies

Blood clots

Serious trauma

Sexually transmitted infection

Other:

Personal History
Childhood Illness

Immunizations?

Tetanus

Date of immunization

Pneumonia

Date of immunization

Hepatitis A

Date of immunization

Hepatitis B

Date of immunization

Chickenpox

Date of immunization

Influenza

Date of immunization

MMR (Measles, Mumps, Rubella)

Date of immunization

Meningococcal

Date of immunization

Any surgeries?

Please provide the year/reason/hospital

Have you ever had a blood transfusion?

Where were you born & raised?

What is your highest education?

Marital status

What is your current or past occupation?

Family History

Family history is:

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

Alcohol Abuse

Anemia

Anesthetic Complication

Arthritis

Asthma

Bladder Problems

Bleeding Disease

Breast Cancer

Colon Cancer

Depression

Diabetes

Heart Disease

High Blood Pressure

High Cholesterol

Kidney Disease

Leukemia

Lung/Respiratory Disease

Migraines

Osteoporosis

Other Cancer

Rectal Cancer

Seizures/Convulsions

Severe Allergy

Stroke/CVA of the Brain

Thyroid Problems

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

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

NONE of the Above

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?

Are you currently sexually active?

Complete the following questions if you are sexually active.

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

Number of partners in last year

Are you in a monogamous relationship?

Are/Is your sexual partner(s)

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

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

List STI:

Treated

Women's Reproductive History

Age of first period

Number of pregnancies

Number of miscarriages

Number of abortions

Do you have regular periods?

Have you reached menopause?

At what age?

Patient Name and Signature:

Medical History Form Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 7

A medical history form is filled out to provide a patient’s current medical record and history. It helps medical professionals determine the best possible medical treatment for patients by determining past, and possibly correlated, medical conditions. Maintaining the security of data collected through medical history forms is crucial for healthcare institutions to stay compliant with legal requirements.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Medical History

General Information

Name

Birth 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?

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

High blood pressure

High cholesterol

Hypothyroidism

Goiter

Cancer

Type:

Leukemia

Psoriasis

Psychiatric condition

Type:

Angina

Heart problems

Heart murmur

Pneumonia

Pulmonary embolism

Asthma

Emphysema

Stroke

Epilepsy (seizures)

Cataracts

Glaucoma

Kidney disease

Kidney stones

Crohn’s disease

Colitis

Anemia

Jaundice

Hepatitis

Stomach or peptic ulcer

Varicose veins

Environmental allergies

Blood clots

Serious trauma

Sexually transmitted infection

Other:

Personal History
Childhood Illness

Immunizations?

Tetanus

Date of immunization

Pneumonia

Date of immunization

Hepatitis A

Date of immunization

Hepatitis B

Date of immunization

Chickenpox

Date of immunization

Influenza

Date of immunization

MMR (Measles, Mumps, Rubella)

Date of immunization

Meningococcal

Date of immunization

Any surgeries?

Please provide the year/reason/hospital

Have you ever had a blood transfusion?

Where were you born & raised?

What is your highest education?

Marital status

What is your current or past occupation?

Family History

Family history is:

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

Alcohol Abuse

Anemia

Anesthetic Complication

Arthritis

Asthma

Bladder Problems

Bleeding Disease

Breast Cancer

Colon Cancer

Depression

Diabetes

Heart Disease

High Blood Pressure

High Cholesterol

Kidney Disease

Leukemia

Lung/Respiratory Disease

Migraines

Osteoporosis

Other Cancer

Rectal Cancer

Seizures/Convulsions

Severe Allergy

Stroke/CVA of the Brain

Thyroid Problems

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

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

NONE of the Above

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?

Are you currently sexually active?

Complete the following questions if you are sexually active.

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

Number of partners in last year

Are you in a monogamous relationship?

Are/Is your sexual partner(s)

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

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

List STI:

Treated

Women's Reproductive History

Age of first period

Number of pregnancies

Number of miscarriages

Number of abortions

Do you have regular periods?

Have you reached menopause?

At what age?

Patient Name and Signature: