Medical History

Family First Physicians Medical History

Please fill out all sections as much as possible
Patient
DOB
Who are your current medical providers?
Provider Name
Specialty/Condition they treat you for
Provider Name
Specialty/Condition they treat you for
Provider Name
Specialty/Condition they treat you for
Provider Name
Specialty/Condition they treat you for
Preventative Care

Please fill out the date when these preventative measures were last completed
Annual Physical   Date
Bone Density (Dexa) scan   Date
Colonoscopy   Date
Cholesterol Test   Date
Dental Exam   Date
Diabetes Screening   Date
Eye Exam   Date
Pap Screen   Date
Mammogram   Date
Prostate Screening   Date
Immunizations

Please fill out the date when these injections were last given
Tetanus (Td or Tdap)   Date
Hepatitis A   Date
Hepatitis B   Date
Pneumonia   Date
HPV (Gardasil)   Date
Shingles   Date
Influenza (Flu)   Date
Meningitis   Date
COVID-19   Date
Please list all medications, supplements, over the counter drugs, creams, and inhalers.
Please put all medications on a separate line
Allergies or intolerances to medications
Please list name of medication and reaction
Do you have a living will?

YesNo
Do you have a medical power of attorney?

YesNo
If you answered "yes" to either, please make sure our office has a copy
If no, would you like information of a copy of advance directive forms?

YesNo
Please check all current or past medical problems or conditions

ADD/ADHDAnemiaAnxietyArthritisAsthmaBipolar DisorderBlood ClotsBlood TransfusionCancerCataractsChronic Lung DiseaseChronic PainDepressionDiabetes Type 1Diabetes Type 2EmphysemaGlaucomaHeart AttackHeart Artery DiseaseHeart FailureHeart MurmurHeartburnHigh Blood PressureHigh CholesterolHIV/AIDSHyperthyroidismHypothyroidismKidney DiseaseMigrainesSeizuresSeasonal AllergiesSexually Transmitted InfectionStomach/Intestine UlcersStrokeSustance AbuseValley FeverOther
Type a question

NoneAppendectomyBreast AugmentationBreast SurgeryCesarean SectionColonCoronary Artery StentCosmetic SurgeryEyeFracture RepairGallbladderHeart BypassHeart Valve SurgeryHernia RepairHysterectomyJoint ReplacementOvariesSpineThyroid SurgeryTonsillectomyTubes TiedVasectomyOther
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Family First Physicians Medical History

Who are your current medical providers?

Preventative Care

Immunizations

If you answered "yes" to either, please make sure our office has a copy