Patient Medical History Form

Health Information
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Gender*
Patient Height
Patient Weight (lbs)
Patient E-Mail
Reason for seeing the doctor:*
Patient Medical History
FAMILY HISTORY
Your Mother?
Cause of Death
Age of Death?
Your Father?
Cause of Death
Age of Death
Your Brother/Sister?
Your Brother/Sister
Please List any Family History of Chronic Diseases or Cancer
ex: diabetes, brother
Please list any drug allergies
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Past Surgical History
Surgical History
Please list any Operations and Dates of Each (ex. hernia repair 2005)
Please list your Current Medications*
Ex: Bystolic 10mg
Healthy & Unhealthy Habits
Exercise

Never1-2 days3-4 days5+ days
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/dayFormer Smoker
Include any other details of your medical history that was not covered above.
Should be Empty:

Health Information