Patient Health History Form

Patient Health History Form
Name

First NameLast Name
Date

MonthDayYear
Date
Reason for Visit
Date of Birth

MonthDayYear
Date
PAST MEDICAL HISTORY

Check all that apply (add dates)

		Dates
Asthma
Arthritis
Anxiety
Cancer
Depression
Diabetes
Epilepsy/Seizures
Heartburn
Heart Disease
High Blood Pressure
High Cholesterol
Kidney/Liver Disease
Osteoporosis
Migraines
Thyroid Disease

Any other health issues:
BASIC HEALTH INFORMATION:
Age of first period
Last menstrual period
Number of Pregnancies
Full Term / Premature deliveries
Number of abortions
Number of living children
Number of miscarriages
SOCIAL HISTORY:
Do you drink alcohol?

NoYes
Amount of alcohol:

dailyweeklymonthly
Do you use tobacco?

NeverFormerCurrent
If current tobacco use, specify amount used.
Do you use Marijuana and/or other illicit drugs?

NeverFormerCurrent
If current drug use, specify amount used.
Occupation
What do you do for exercise?
Marital Status?
Lives with?
Children?
Level of highest education?
PAST SURGICAL HISTORY:

Write the type of surgery and year.

	Type	Date
Surgery #1
Surgery #2
Surgery #3
Surgery #4

Date of Last Pap Smear:

MonthDayYear
Date
Pap Smear

NormalAbnormal
Date of Last Colonoscopy:

MonthDayYear
Date
Colonoscopy

NormalAbnormal
Date of Last Mammogram:

MonthDayYear
Date
Mammogram

NormalAbnormal
Date of Last Dexa Scan:

MonthDayYear
Date
Dexa Scan

NormalAbnormal
Date of Last PSA:

MonthDayYear
Date
PSA

NormalAbnormal

Vaccines

	Check if Yes	Date
Shingles
Pneumococcal
Tetanus
COVID-19
Flu

Current Medications

	Name	Dosage	Frequency
1.)
2.)
3.)
4.)
5.)

ALLERGIES: (Write allergy & reaction)
Latex

YesNo
Iodine

YesNo
Eggs

YesNo
No Allergies

No Allergies
FAMILY MEDICAL HISTORY

Mark M for Mother, F for Father, S for Sister, B for Brother, A for Aunt, U for Uncle, PGF for Paternal Grandfather, PGM for Paternal Grandmother, MGF for Maternal Grandfather, MGM for Maternal Grandmother. Add Ages if possible.

	Which Family Member/Members	Age (if known)
Blood Clots
Diabetes
Drug or Alcohol Abuse
Heart Attack
High Blood Pressure
High Cholesterol
Osteoporosis
Stroke
Thyroid Disease
Cancer

If yes to family history of cancer, please specify which type/types.
Other Family Medical History: