Patient History Form

DEMOGRAPHIC INFORMATION:

Name:

Today's Date

Date of Birth:

Sex:

Male Female

Address

City:

State:

Zip Code:

Home#:

Work#:

Cell#:

Email Address:

Emergency Contact:

Phone#:

Relation:

Primary Pharmacy:

Mail Order Pharmacy:

Race: (Select One)

American Indian/Alaskan Native Asian African American/Black Native Hawaiian / Other Pacific Islander Caucasian/White Refused

Ethnicity

Not Hispanic / Latino Non-Hispanic African Refused

Primary language:

NEW PATIENT MEDICAL HISTORY FORM:

Preferred Name:

Date:

What Pharmacy do you use?

Were you referred to our office?

Yes No

If yes, by whom?

Review of Medical Symptoms:

At this time do you have any following complaints?

Please answer Yes or No

Constitutional:

Fatigue

Weight Change

Fever

Eyes:

Yes No

Ear/Nose/Throat:

Yes No

Cardiovascular:

Yes No

Skin:

Yes No

Respiratory:

Yes No

Neurologic:

Yes No

Gastrointestinal:

Yes No

Psychiatric:

Yes No

Genitourinary:

Yes No

Endocrine

Yes No

Musculoskeletal

Yes No

Allergies

Yes No

Heme/Lymphatic

Yes No

Medical Allergies:

Do you have a Latex Allergy? (Yes or No)

Yes No

Please list all known allergies to medications and your reaction. If none, state N/A:

Have you ever had any complications with Anesthesia? (Yes or No)

Yes No

(If yes,what?)

Do you have difficulty stopping bleeding or do you have a bleeding disorder (Y/N)

Yes No

Family Medical History:

Does any member of your immediate family (Parents/Siblings/Children) have or have ever been treated for the following: yes or no (if Yes) Whom?

Bleeding Disorder

Complication with Anesthesia

High Blood Pressure

Asthma/Emphysema

Heart Disease

Cancer : (Type, Date, Treatment)

Other:

Social History:

You’re Age:

Marital Status:

Single Married Divorced Widowed

Number of Children:

Who lives at home with you?

Your Employer:

(retired) previous Employer:

Do you or have you ever used:

Cigarettes

Cigars

Tobacco

Amount per day:

Years:

Years since you quit:

Do you drink Alcohol?

Drinks per day:

Type:

Do you or have you ever abused drugs? Y/N Type:

Patient Name:

Date of Birth:

Medical History:

Have you ever been hospitalized? (Reason?)

Please list any current or past medical conditions you have been diagnosed with:

Have you ever been diagnosed with cancer? (If so what type)

Have you ever been diagnosed with HIV / Hepatitis /Etc. (Y/N) if Yes, what type?

Past Surgical History:

Have you ever had surgery? (What type?)

Have you ever had any procedures or surgeries for your heart?

Patient Name:

Date of Birth:

Have you ever had any complications with surgery?

Yes No

If yes, what

Medications:

Please list all medication that you currently take including vitamins and non-prescription of alternative medications, the dosage and frequency. If none, please state N/A:

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