Patient Medical History Form

Health Information
Patient Name *

First Name Last Name
Patient Birth Date *

Month Day Year
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)

Anemia Asthma Arthritis Cancer Gout Diabetes Emotional Disorder Epilepsy Seizures Fainting Spells Gallstones Heart Disease Heart Attack Rheumatic Fever High Blood Pressure Digestive Problems Ulcerative Colitis Ulcer Disease Hepatitis Kidney Disease Liver Disease Sleep Apnea Use a C-PAP machine Thyroid Problems Tuberculosis Venereal Disease Neurological Disorders Bleeding Disorders Lung Disease Emphysema
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

Never 1-2 days 3-4 days 5+ days
Alcohol Consumption

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day
Caffeine Consumption

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day
Do you smoke?

No 0-1 pack/day 1-2 packs/day 2+ packs/day Former Smoker
Include any other details of your medical history that was not covered above.
Should be Empty:

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Health Information