Patient Health History

Please correct the errors described below.

Name:

Today's Date:

Age:

Date of Birth:

What is your reason for this visit?

Date symptoms first occurred or injury happened:

If injury, where did accident occur?

Have you previously had any type of surgery?

Is there a family history of:

Arthritis

Blood disorder

Cancer

Diabetes

Heart disease

Stomach/bowel disorder

High blood pressure

Respiratory problems

Hepatitis

Thyroid disease

Other

Check symptoms you currently have or have had in the past year

Depression

Dizziness

Headache

Loss of sleep

Loss of weight

Stomach pain

Chest pain

Numbness

Joint pain or weakness

If you checked Joint pain or weakness:

Arms

Knees

Feet

Legs

Hips

Shoulders

Back

Neck

Check conditions you have or have had in the past

AIDS

Alcoholism

Anemia

Anorexia

Appendicitis

Arthritis

Asthma

Bleeding disorders

Breast lump

Bronchitis

Bulimia

Cancer

Cataracts

Drug dependency

Chickenpox

Diabetes

Emphysema

Epilepsy

Glaucoma

Goiter

Gonorrhea

Gout

Heart disease

Hepatitis

Hernia

Herpes

High cholesterol

HIV Positive

Kidney disease

Liver disease

Migraine headaches

Mononucleosis

Multiple sclerosis

Pacemaker

Pneumonia

Polio

Psychiatric care

Stroke

Suicide attempt

Thyroid problems

Tuberculosis

Ulcers

Venereal disease

MEDICATIONS List medications you are currently taking

ALLERGIES to medications or substances

Pharmacy Name:

Phone #:

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