Medical History Form

Patient Medical History
Please answer these questions as completely and honestly as possible, so we can help you be as healthy as you can be.
Today's Date*

MonthDayYear
Date
Patient Information
Name*

PrefixFirst NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Occupation*
Last Grade Completed in School:*
Marital Status*
Email
example@example.com
Primary Phone Number

Area CodePhone Number
Can we text you at this number?

YesNo
Secondary Phone Number

Area CodePhone Number
Can we text you at this number?

YesNo
Medical Information

Family Medical History

Please list any hospitalizations or surgeries:

Check all conditions that apply to you:


Headaches
Shortness of Breath
Heart Palpitations
Chest Pain
Dizziness/Fainting
Peripheral Vascular Disease
Allergies/hay fever
Asthma
Bronchitis
Pneumonia
Ulcer
GI Disorder
Early Morning Awakening
Daytime Drowsiness
Difficulty Falling Asleep
Lactose Intolerance
Gallbladder Disease
Renal Disease
Prostate Disease
Bowel Irregularity
Incontinence
Sexual/Menstrual Dysfunction
Veneral Disease
Frequent Infections
Hepatitis
Anemia
Arthritis
Osteoarthritis
Hearing Loss
Problems with reading or vision loss
Snoring
Nervousness
Depression
Gout
Scarlet Fever
Chronic Rashes
Rheumatic Fever
AIDS/HIV
Past Stroke
Past Heart Attack
Diabetes

Date of last tetanus shot:

MonthDayYear
Date
Date of last flu shot:

MonthDayYear
Date
Date of last pneumonia vaccine:

MonthDayYear
Date
Do you smoke?*

YesNo
How long have you smoked?
How many packs per day?
Are you interested in quitting?

YesNo
Do you drink?*

YesNo
How many days per week?
Type:

BeerWineLiquor
How many drinks at a time?
What exercise do you enjoy?
How often do you exercise?
What prevents you from exercising?
Regular Method of Transportation:*

Drive my own carFamily/friends drive meWalkBusOther
Other health questions/concerns:
Additional Info for Patients with Diabetes:
Have you been told by a doctor that you have diabetes?

YesNo
If yes, when?
Please list all diabetes medications that you are taking:
Do you feel that your diabetes medicines are working properly?

YesNo
What was your most recent A1c level?
Insert Number or "Don't Know"
Check any of these tools that you currently have for managing your diabetes:

MedicineSyringesBlood sugar monitor/stripsInsulinLancetsFamily SupportFriend SupportChurch supportUnderstanding of diabetesBlood sugar diaryAn eating plan that you enjoy
Would you like to learn more about managing your diabetes?

YesNo

In the past 12 months, have you seen or been to:

	Number of Visits	Reason
Primary Doctor
Emergency Room
Overnight Hospital Stay
Eye Doctor
Foot Doctor
Diabetes Education Class or Counseling

What was your most recent fasting blood sugar at home?
Insert number or "Don't Know"
When do you check your blood sugar? Check all that apply:

I do not check itBefore mealsBefore an insulin shotAt bedtimeTwice a dayWhenever I think about itOther
Do you have strips to check your blood sugar?

YesNo
Would you like to learn more about checking your blood sugar?

YesNo
When your blood sugar is low, what do you do?
What health concerns would you like to discuss today?

DiabetesWeightCholesterolBlood pressureEyesKidneysTingly feet/handsDepressionSexual problemFrequent infectionFoot problemStomach problem
What type of eating plan are you on?

No eating planCount carbohydrates"Seefood" plan (I eat the food I see!)Drink lots of fluidsI would like to learn about eating betterOther
What's the hardest thing about having diabetes?
Should be Empty:

Patient Medical History