Medical History & Physical form

Infectious Diseases Consultants of the Treasure Coast

Patient Name:

Today's Date:

Date of Birth:

Social Security Number:

Email:

Primary Care Physician:

Referred by:

Preferred Pharmacy:

Diagnostic Center:

Reason for today's visit:

FAMILY HISTORY

Mother

Living Deceased

Medical Conditions (if living)

Cause of Death (Deceased)

Father

Living Diseased

Medical Conditions (if living)

Cause of Death (Deceased)

List how many children:

Son(s)

Daughter(s)

Add Another Medical Condition

Alcohol Consumption

Yes No Quit

How often

Type

Quit Date

Recreational Drugs

Yes No Quit

How often

Type

Quit Date

Tobacco Use

Yes No Quit

How often

Type

Quit Date

Occupation:

Yes No

Occupation:

Sexual Partners:

Male Female Both

Sexually Active:

Yes No

Marital Status:

Married Divorced Widowed Significant Other Single

Add another medication allergy

Medication: (Please include vitamins and supplements)

Add another medication

Medical History

Anemia

Yes No

Type, Diagnosis Date:

Arthritis

Yes No

Type, Diagnosis Date:

Atrial Fibrillation

Yes No

Type, Diagnosis Date:

Blood Clots

Yes No

Type, Diagnosis Date:

Cancer

Yes No

Type, Diagnosis Date:

Cellulitis

Yes No

Type, Diagnosis Date:

Colitis

Yes No

Type, Diagnosis Date:

COPD

Yes No

Type, Diagnosis Date:

Crohn's Disease

Yes No

Type, Diagnosis Date:

Diabetes

Yes No

Type of Diabetes

Type 1 Type 2

Diagnosis Date:

GERD

Yes No

Type, Diagnosis Date:

Heart Attack

Yes No

Type, Diagnosis Date:

Hepatitis

Yes No

Type of Hepatitis

A B C

Diagnosis Date:

Hypertension (High Blood Pressure)

Yes No

Type, Diagnosis Date:

Hypothyroidism

Yes No

Type, Diagnosis Date:

Lung Disease

Yes No

Type, Diagnosis Date:

Lyme's Disease

Yes No

Type, Diagnosis Date:

MRSA

Yes No

Type, Diagnosis Date:

Multiple Sclerosis

Yes No

Type, Diagnosis Date:

Osteoporosis

Yes No

Type, Diagnosis Date:

Psoriasis

Yes No

Type, Diagnosis Date:

Stroke

Yes No

Type, Diagnosis Date:

Chronic Kidney Disease

Yes No

Type, Diagnosis Date:

HIV/AIDS

Yes No

Date Contracted:

Surgical History

Appendectomy

Yes No

Type:

Date:

Arthroscopic Surgery

Yes No

Type:

Date:

Cosmetic Surgery

Yes No

Type:

Date:

Gallbladder Removal

Yes No

Type:

Date:

Hernia Repair

Yes No

Type:

Date:

Hysterectomy

Yes No

Type:

Date:

Joint Replacement

Yes No

Type:

Date:

Pacemaker Placement

Yes No

Type:

Date:

Skin Cancer Removal

Yes No

Type:

Date:

Spinal Surgery

Yes No

Type:

Date:

Tonsillectomy

Yes No

Type:

Date:

Vascular Surgery

Yes No

Type:

Date:

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