Pre-Appointment Medical History

MEDICAL HISTORY

Your answers to the following questions will help us to understand your medical history and the concerns you would like to discuss with your provider. Please fill out as much of this questionnaire as possible.
Patient Legal Name *

First Name Middle Name Last Name Suffix
Patient's Date of Birth

Month Day Year
Date
Date Completed:

Month Day Year
Date
Please list any medication allergies and reactions:
Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which you are currently taking. Please note the dosage if possible.
Please indicate if you have ever had the following conditions:
Please explain any conditions indicated above:
Please list any surgeries or hospital stays you have had and approximate date/year:
Type of surgery / reason for hospitalization / location / dates
Do you have Regular Periods?
If no, please explain:
Number of Pregnancies
Number of Living Children
Number of Miscarriages
Number of Abortions
Are you currently receiving care from any other doctors, chiropractors, or other health care professionals? If yes, we would like to know whom and what they are treating you for, so we can coordinate your care:
Please note dates of your most recent immunizations:
Influenza:
Hepatitis B:
Tetanus/Tdap:
Pneumonia:
Other immunization name and date:
Please note when the following tests done, if applicable, and what the results were, if known:
Cholesterol
HIV
Pap smear/pelvic
Colonoscopy
Mammogram
Hepatitis C
Blood in stool
FAMILY HISTORY

Please check any diseases applicable to your family

N/A

Mother

Father

Sister

Brother

Grandmother
(Maternal)

Grandfather
(Maternal)

Grandmother
(Fraternal)

Grandfather
(Fraternal)

Cancer

Diabetes

Heart Disease

High Blood Pressure

High Cholesterol

Osteoporosis

Mental Illness

Stroke

Thyroid Disease

Alcohol/Drug

Other

Other Comments Regarding Family History:
SOCIAL HISTORY

Please check yes/no for each question and explain as necessary
Do you smoke or use any tobacco products?

Yes No
Number of Cigarettes Each Day?
Types of tobacco used?
For how many years?
Quit smoking, date:

Month Day Year
If unsure, please estimate
Do you drink alcohol?

Yes No
How much alcohol do you drink?
How often do you drink?
Have you ever felt you should cut down on drinking?

Yes No
Have you regularly used drugs?

Yes No
What kind of drugs?
Are you still using drugs?

Yes No
Who lives with you at home?
How many children do you have?
Are you employed?

Yes No
What is your occupation?
Do you ever feel sad or depressed?

Yes NO
Do you have any financial issues limiting access to food, shelter, or medical care?

Yes No
Have you experienced any major life changes within the last year? (i.e., marriage, divorce, death of a loved one, illness/injury, job change)

Yes No
Do you have some form of church or spiritual support?

Yes No
What is your sexual preference?

Women Men Both
Do you feel you are at risk for HIV/AIDS?

Yes No
Do you use any form of birth control?

Yes No
What type of birth control do you use?
Please list any other questions or concerns you may have
You must click "Submit Appointment" or your submission will not be received
Should be Empty:

MEDICAL HISTORY

FAMILY HISTORY

SOCIAL HISTORY