Medical History Form

Medical History Form
Full Name *

First Name Last Name
Do you have any medication allergies? *

Yes No Not Sure
If yes, Please List
Severity
Onset
Reaction
Do you have any Food allergies? *

Yes No Not Sure
If Yes, Please List
Severity
Onset
Reaction
Do you have any Environmental allergies (pollen,latex etc)? *

Yes No Not Sure
If Yes, Please List
Severity
Onset
Reaction
Are you currently taking any medication, including Herbs, Supplements etc? *

Yes No
If so, please list:
Have you had Surgery? *

Yes No
If so, please list:
Gender identity *

Male Female Transgender Male/Trans Man/Female-to-Male Transgender Female/Trans Woman/Male-to-Female Genderqueer, neither exclusively Male nor Female Additional gender category or other (please specify) Patient declines to specify
Sexual orientation *

Straight or heterosexual Lesbian, gay, or homosexual Bisexual Something else, please describe Don't know Patient declines to specify
Past medical history (Check the conditions that apply to you ): *

Diabetes High blood pressure Heart Disease Cancer Stroke Seizures Lung Disease (Asthma, COPD, etc.) HIV None
Other Health Issues
Family History ( Check the conditions your family has a history of) *

Diabetes High Blood Pressure Heart Disease Lung Disease (Asthma, COPD, etc) Cancer Stroke Seizures None Unknown
Preventative Care History *

Routine Physical Eye Exam Colonoscopy Bone Density Scan Flu Shot Pneumonia Vaccine Mammogram (F) Pap Smear (F) Prostate Exam( M) None
When was the last time you had the preventative exam you checked off done?
How often do you consume Tobacco? *

Daily Weekly Monthly Occasionally Never
How often do you consume alcohol? *

Daily Weekly Monthly Occasionally Never
Do you use or do you have history of using illegal drugs? *
Check the symptoms that you have experienced in the PAST 6 WEEKS *

Fever/Chills Weight Loss Weigh Gain Fatigue/Malaise/Generalized weakness Headaches/Migraines Dizziness Sinus Pain/Pressure/Discharge Excessive snoring Wheezing/Chronic Cough Shortness of breath Chest pain, pressure or tightness Swelling of hands/feet/ankles Nausea/Vomiting Abdominal pain Heartburn Constipation Diarrhea Bloating Stiffness/Pain in joints/muscles Joint swelling Bleeding/Easy bruising Excessive urination Excessive thirst/hunger Hot flashes Painful/Bloody urination Difficulty urinating/Night-time urination Urinary incontinence (leakage) Sexual Difficulties Painful Intercourse Reduced Morning Erections Reduced Sex Drive Difficulty in Orgasm Irritability Rash Anxiety/Panic Attacks Concentration Difficulty Feelings of Guilt Insomnia/Problems with Sleep Loss of energy Thoughts of harming self or others None
How healthy do you feel in general?
I give my express permission to DOKcare Medical, to obtain and access to all of my medical records. I understand that my personal and medical information may be stored on a password protected secure cloud service.
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