MEDICAL HISTORY FORM
Date
-
Month
-
Day
Year
Date
PATIENT NAME:
First Name
Last Name
DATE OF BIRTH
-
Month
-
Day
Year
Date
AGE
DRUG ALLERGIES:
Yes
NO
IF yes, PLEASE LIST
MEDICATIONS YOU ARE TAKING:
PAST MEDICAL HISTORY
Check all that applies:
Allergies
Anemia
Arthritis
Bowel Irregularities
Chest Pain
Chronic Pain
Depression
Dizzy/ Fainting
Diabetes
GERD
Gallbladder
Gout
Headache/ Migraine
Heart Murmur
Heart Palpitations
Hepatitis
High Cholesterol
Hypertension
Pneumonia
Prostate Disease
Rheumatic Fever
Rashes
Seizures
Sexual/ Menstrual
Dysfunction
Kidney Disease
Date of last Immunization:
FLU
-
Month
-
Day
Year
Date
TETANUS
-
Month
-
Day
Year
Date
PNEUMONIA
-
Month
-
Day
Year
Date
MMR
-
Month
-
Day
Year
Date
PPD
-
Month
-
Day
Year
Date
COVID
-
Month
-
Day
Year
Date
FAMILY HISTORY
( check all that applies)
Self
Father
Mother
Sibling
Children
Autoimmune Disease
Bleeding or Blood disorders
Cataracts / Glaucoma / Eye Disease
Cancer
Diabetes
Chronic Headaches/ Migraines/ seizures
Heart Disease / High cholesterol / Hypertension
Kidney Disease
Thyroid Disease
Mental Illness / Anxiety/ Depression
Bleeding or Blood disorders
HOSPITALIZATION / SURGERIES
Date
-
Month
-
Day
Year
Date
HOSPITALIZATION / SURGERIES
Date
-
Month
-
Day
Year
Date
HABITS / RISK FACTORS
Do you smoke or vape, tobacco?
Yes
No
TYPE
AMOUNT
HOW LONG
Do you drink alcohol?
Yes
No
TYPE
AMOUNT
Do you use marijuana or drug?
Yes
No
TYPE
AMOUNT
Do you use exercise?
Yes
No
TYPE
AMOUNT
WOMEN HEALTH
First Age of Menstrual Cycle:
Last Menstrual date:
-
Month
-
Day
Year
Date
Type of Birth Control:
Total Pregnancies:
Total Full Term:
Total Children Alive:
Last Pap Smear:
Last Mammogram:
ADVANCE DIRECTIVES
Do you have a health care surrogate?
Yes
No
IF YES: List Name(s)
Do you have an Advance Directives or Living Will?
Yes
No
( If yes, please provide a copy)
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