Patient Medical History Form

Health History
Patient Name *

First Name Last Name
Patient Birth Date *

Month Day Year
Patient E-Mail *
example@example.com
Reason for seeing the doctor: *
Have you been exposed to or had symptoms of COVID-19 in the past 10 days *

Yes No
Patient Medical History
Please list any drug allergies and reactions *
Please list your Current Medications and dosage, include supplements *
Have you ever had (Please check all that apply) *

Trauma/violence Abuse Allergies (food, seasonal, environmental) Anesthesia complications Drug latex allergies or reactions History of abnormal pap/HPV History of STIs Anemia Heart Disease Heart Attack Stroke/TIA Heart palpitations High Blood Pressure History of preeclampsia High cholesterol Deep vein thrombosis or pulmonary embolism Varicosities Thrombophilias History of blood transfusion Migraines Headaches Anxiety Depression Bipolar Mood disorder Insomnia Epilepsy or seizures Diabetes History of gestational diabetes Hyperthyroidism Hypothyroidism Other thyroid issues Acne (cystic or HS) ART (IVF or FET) Endometriosis Infertility Menstrual irregularities PCOS Postmenopausal bleeding Vaginitis/yeast, recurrent/chronic Pituitary/Adrenal disorder Uterine fibroids Uterine polyps Osteoporosis Osteopenia Bladder problems Frequent UTIs Incontinence Kidney disease Kidney infections Kidney stones Acid reflux or GERD Crohn's disease Diverticulosis/diverticulitis Eating disorder Gallbladder disease/stones Gastritis/ulcer disease Hepatitis Irritable bowel Liver disease GI problems Pancreatic disease colon polyps Ulcerative colitis Asthma Chronic bronchitis Lung disease Sleep apnea COPD Emphysema Fibromyalgia Autoimmune disease Lupus Arthritis Rheumatoid arthritis Dermatological disorders Eczema Psoriasis Back pain Joint pain Cataracts Glaucoma Vision loss Hearing loss Breast cancer Fibroadenoma of breast Other benign breast disorder or mass Ovarian cancer Ovarian cysts Uterine cancer Colon cancer Melanoma Skin cancer (SCC/BCC) Other cancer Birth defects or inherited disorders Other
Other illnesses:
Please list current health problems, even if controlled with medications *
Please list any surgeries and date/year of each *
Exercise

Never 1-2 days 3-4 days 5+ days
Diet

Regular diet Gluten free diet Dairy free diet Vegetarian diet Keto diet Paleo diet Other
Alcohol Consumption

I don't drink 1-2 glasses/week 3-4 glasses/week 5-7 glasses/week 8-10 glasses/week 11-14 glasses/week 15+ glasses/week
Caffeine Consumption

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day
Do you smoke (use nicotine products), currently or in the past?

No, never Former 0-1 pack/day 1-2 packs/day 2+ packs/day Other
Do you use recreational drugs? If yes, what?
Abuse history

History of physical abuse History of sexual abuse Safe in current relationship/situation Not safe currently, need resources for help
Any comments regarding your Medical History
Family History - please list health issues for relatives (parents, maternal grandparents, paternal grandparents, maternal aunts/uncles, paternal aunts/uncles, siblings, children) *
Are you still having menstrual periods? *
First period was at age: *
First day of your last period: *
Periods are: *

Very painful Mild cramping Heavy flow Moderate flow Light flow
How many days do you bleed for? *
If you are menopausal, what age did you become menopausal, and have you had any bleeding since then?
What is your relationship status?

Single Married Partnered In a relationship Divorced Separated Widowed
Are you sexually active ? *
Current method of birth control? *
How many sexual partners do you currently have? *
In the past 3 months, have you had any new partners? *
Do you have a history of abnormal pap smears or HPV? If yes, when and what were the results? Have you have colposcopy or treatment for these? *
When was your last pap smear? *
Have you been vaccinated for HPV? *
Date of last mammogram? *
Date of last colonoscopy?
Date of last DEXA scan (bone density)?
Have you been pregnant? How many times? How many births, and number of vaginal or c-sections? How many miscarriages, ectopics, terminations? *
Weight of your largest baby?
Age at first delivery of your first child?
Should be Empty:

Health History

Patient Medical History