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?

Yes No
Do you have a medical power of attorney?

Yes No
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?

Yes No
Please check all current or past medical problems or conditions

ADD/ADHD Anemia Anxiety Arthritis Asthma Bipolar Disorder Blood Clots Blood Transfusion Cancer Cataracts Chronic Lung Disease Chronic Pain Depression Diabetes Type 1 Diabetes Type 2 Emphysema Glaucoma Heart Attack Heart Artery Disease Heart Failure Heart Murmur Heartburn High Blood Pressure High Cholesterol HIV/AIDS Hyperthyroidism Hypothyroidism Kidney Disease Migraines Seizures Seasonal Allergies Sexually Transmitted Infection Stomach/Intestine Ulcers Stroke Sustance Abuse Valley Fever Other
Type a question

None Appendectomy Breast Augmentation Breast Surgery Cesarean Section Colon Coronary Artery Stent Cosmetic Surgery Eye Fracture Repair Gallbladder Heart Bypass Heart Valve Surgery Hernia Repair Hysterectomy Joint Replacement Ovaries Spine Thyroid Surgery Tonsillectomy Tubes Tied Vasectomy Other
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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