Manhattan Primary Care-Past Medical History

Manhattan Primary Care

Bradley K. Harrison, MD, FAAFP | Kyle E. Platz, DO Kerri Maxcy PA-C | Michelle Oehm, APRN-C
Past Medical History
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Preferred Pharmacy*
Occupation/Employer and Job Title
If none, type n/a
Student Status
If none, type n/a
Do you currently use any tobacco products?*

YesNo
Never used tobacco
Current smoker   I currently smoke (insert number) packs per day. I have smoked for(insert number) years.
Previous smoker   I previously smoked (insert number) packs per day. I smoked for (insert number) years. My quit date was   (insert date)
Currently use chewing tobacco
Previously used chewing tobacco
Currently use vape   I currently vape(insert number) pods per day. I have vaped for(insert number) years.
Previously used a vape    I previously vaped(insert number) pods per day. I smoked for   years. My quit date was(insert date)
Alcohol History*

No alcoholRare alcoholLess than 5 alcohol drinks weekly5-10 alcohol drinks weeklyGreater than 10 alcohol drinks weeklyGreater than 20 alcohol drinks weeklyCurrently not drinking, but history of alcoholismOther
Are you, or is there a chance you may be pregnant?

I am pregnantI am not pregnantI am unsure if I am pregnantNot applicable
Father: Living Deceased Age: Age   Medical History Father's Medical History*
Mother: Living Deceased  Age: Age   Medical History Mother's Medical History*
Brother: Living Deceased  Age: Age   Medical History Brother's Medical History
Sister:  Living Deceased  Age: Age  Medical HistorySister's Medical History
Health Maintenance (Check all that are up-to-date)*

Pertussis (Tdap)PneumoniaShinglesInfluenzaColonoscopyMammogramBone DensityPap SmearUnknown
Specify Dates for Up-to-Date Health Maintenance (those checked above)*
If none, type n/a
Past Medical History*

NoneStroke/Mini-Stroke/CVASeizuresMigrainesHeart DiseaseHigh Blood PressureHigh CholesterolBlood Clots/DVT/PEGastrointestinal DiseaseAsthmaCOPD/EmphysemaSleep ApneaDiabetesThyroid DiseaseKidney DiseaseAnxietyDepressionBipolarCancerOther
Do you currently have any of these symptoms?*

NoneChillsFeversWeight LossWeight GainNight SweatsRashBlurred VisionHeadacheCoughChest painsPalpitationsAbdominal painHeartburnSwelling of legs or armsPassing OutAnxietyFeeling down, depressed or hopelessLittle interest or pleasure in doing thingsAppetite changesAbnormal bleedingOther
Surgical History (Type of Surgery/Reason, Year)*
If none, type n/a
Medication Allergies (Name of Medication/Product, Reaction)*
If none, type n/a
Medications/Supplements (Name, Strength, Frequency)*
If none, type n/a
Type of Birth Control
n/a if not applicable
Other Providers You See (Name, Specialty)*
If none, type n/a
Most Recent Primary Care Physician*
If none, type n/a
Signature*

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