Patient Medical History Form

Patient Medical History
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Physician Name *
Date of Appointment *

Month Day Year
Date
Time of Appointment *

: Hour Minutes AM/PM Option
Medical & Surgical History

Please indicate if the patient has had any of the following.
Medical disorders:

AIDS/HIV Alcoholism Alzheimer's Anemia Rheumatoid Arthritis Asthma Blood Clot (Leg) Blood Clot (Lung) Blood Thinners Cancer (Breast) Cancer (Lung) Cancer (Prostate) COPD Depression Diabetes Drug Abuse Gout Heart Attack High Blood Pressure Hepatitis Kidney Disease Osteoarthritis Seizures Sleep Apnea Stroke Ulcers, Bleeding
Surgical history:

Cardiac (Heart) Carpal Tunnel (Left Wrist) Carpal Tunnel (Right Wrist) Arthroscopy (Left Elbow) Arthroscopy (Right Elbow) Arthroscopy (Left Shoulder) Arthroscopy (Right Shoulder) Arthroscopy (Left Ankle) Arthroscopy (Right Ankle) Arthroscopy (Left Knee) Arthroscopy (Right Knee) Arthroscopy (Left Hip) Arthroscopy (Right Hip) Left Hip Replacement Right Hip Replacement Left Knee Replacement Right Knee Replacement Spinal Fusion Laminectomy Fracture Surgery
Family History History

Please indicate if the patient's family members have had any of the following.
Patient's Father:

AIDS/HIV Anemia Rheumatoid Arthritis Blood Clot (Leg) Blood Clot (Lung) Cancer (Breast) Cancer (Lung) Cancer (Prostate) Coronary Artery Disease Diabetes Gout Heart Attack Hemophilia Hypertension Kidney Disease Liver Disease Muscle Disease Osteoporosis
Patient's Mother:

AIDS/HIV Anemia Rheumatoid Arthritis Blood Clot (Leg) Blood Clot (Lung) Cancer (Breast) Cancer (Lung) Cancer (Prostate) Coronary Artery Disease Diabetes Gout Heart Attack Hemophilia Hypertension Kidney Disease Liver Disease Muscle Disease Osteoporosis
Patient's Siblings:

AIDS/HIV Anemia Rheumatoid Arthritis Blood Clot (Leg) Blood Clot (Lung) Cancer (Breast) Cancer (Lung) Cancer (Prostate) Coronary Artery Disease Diabetes Gout Heart Attack Hemophilia Hypertension Kidney Disease Liver Disease Muscle Disease Osteoporosis
Review of Systems

Please indicate if the patient has any of the following.
Constitutional:

Weight Loss/Gain Weakness Fatingue Fever
Cardiovascular:

High Blood Pressure Chest Pain Rheumatic Fever Palpitations Has Pacemaker
Musculoskeletal:

Joint Pain Arthritis Muscular Weakness Stiffness Muscular Pain
Musculoskeletal:

Joint Pain Arthritis Muscular Weakness Stiffness Muscular Pain
Eyes:

Glasses or Contacts Blurred Vision Glaucoma Cataracts Excessive Tearing
Skin:

Rashes Sores Lumps Dryness Itching
Blood or Lymph:

Anemia Easy Bruising Easy Bleeding Swollen Glands
Ear Nose Mouth Throat:

Ears Ringing Earaches Hearing Aid Frequent Colds Nasal Discharge Hay Fever Nosebleeds Dentures Bleeding Gums Frequent Sore Throats
Neurological:

Headache Dizziness Seizures Loss of Sensation Vertigo
Gastrointestinal:

Heart Burn Rectal Bleeding Abdominal Pain Gallbladder Trouble Hepatititis
Respiratory:

Shortness of Breath Cough Wheezing Asthma Bronchitis
Genitourinary:

Blood in Urine Urinary Infections Kidney Stones Burning Urination Sexual Disease
Endocrine:

Thyroid Trouble Excessive Sweating Excessive Thirst
Immunologic:

Reactions to Drugs Skin Rashes Reactions to Foods
Psychological:

Nervousness Depression Mood Changes
Social History
Do you use tobacco? *

Yes No Former User
Do you use alcohol? *

Yes No
Do you use caffeine? *

Yes No
Do you use illicit drugs? *

Yes No
Which hand is your dominant hand? *

Right Left Either
Could you be preganant?

Yes No
Allergies to following medications or substances?

No Known Allergies Amoxil Ampicillin Aspirin Bactrim Ceftin Cefzil Codeines Depakene Dilantin Insulin Iodine/Shellfish Keflex Lamictal Lidocaine Novacaine Pediazole Penicillin Sulpha Drugs Suprax Septra Tegretol Vantin
Other allergies:

Latex IVP/X-Ray Dye Metal Egg/Avian (Bird)
Please list any other allergies
Should be Empty:

Patient Medical History

Medical & Surgical History

Family History History

Review of Systems

Social History