Patient Medical History

Patient Medical History
Patient Medical History
Name *

First Name Last Name
Name *
Date *

Month Day Year
DOB *
Age *
Height *
Weight *
Referring Physician
Chief complaint/reason you are here *
How long have you had this problem *
Medication Allergies
Latex Allergy *

Yes No
Had MRSA (Methucillin-Resistant Staphylococcus Aureus) *

Yes No
Previous surgeries & approximate year
Medical problems current and/or chronic
Have you ever had or been treated for any of the following problems?
Gastrointestinal

Nausea or Vomiting Abdominal Pain Heartburn/Indigestion Constipation Diarrhea Ulcers Hiatal Hernia Gallstones Pancreatitis Colitis Crohn's Disease Blood in stool Colon Cancer Hepatitis HIV/AIDS
Genito-Urinary

Kidney Stones Kidney Infection Prostate Trouble Bladder Troubles Ovarian Cancer Uterine Cancer
Endocrine

Diabetes Thyroid Trouble
Hematology

Anemia Bleeding Tendency Blood Clot
Pulmonary

Sleep Apnea Asthma Bronchitis Emphysema Pneumonia Tuberculosis
Breast

Fibrocystic Changes Breast Cancer Nipple Discharge Breast Lumps
Cardiovascular

High Blood Pressure Heart Murmur Heart Attack Heart Failure Irregular Heart Rate Pain in Leg w/ Walking
Neurological

Stroke Weakness on one side Seizures Slurred Speech Mental Illness
Heart Attack: If YES, when?
Other

Arthritis Hayfever Shingles Skin Cancer
Social History
Do you smoke? *

Yes No
How often?
Do you drink alcohol? *

Yes No
How often?
Marijuana? *

Yes No
How often?
Family History
Colon Cancer:
Relative
Age
Breast Cancer:
Relative
Age
Do you exercise? *

Yes No
If so, how often?
Pharmacy
City

Current and Recently Stopped Medications (If none put N/A in first row) *

	Drug Name	Dosage	Frequency	Method of Intake
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug

Current Medications & Dosages: ( If none, type none.)
Are you on any Blood thinners? If so, please list them here (Plavix, Asprin, etc)
Signature *
Date

Month Day Year
Should be Empty:

Patient Medical History

Social History

Family History