Medical History

Name

DOB

Date

Reason for today’s visit

Allergies (Please include reaction)

Occupation

Do you have a Living Will?

Yes No

If Yes, what the content?

No Resuscitation

No Feeding Tubes

No Medication Support

No Mechanical Ventilation

Other

Do you have a Durable Power of Attorney?

Yes No

Name

Cancer Screening

If over 45 years old, Have you had a Colonoscopy within the last 10 years?

Yes No

If Yes, Name of Doctor

Contact

Female Only:

If you are between 21-64 years old have you had a PAP Smear within the last 3 years?

Yes No

If Yes, Name of Doctor

Contact

If you are between 50-74 years old have you had a Mammogram within the last 2 years?

Yes No

If Yes, Name of Doctor

Contact

Diabetes Screening

Have you been diagnosed with Diabetes?

Yes No

If yes, have you had a Diabetic Eye Exam within the last 12 months?

Yes No

If Yes, Name of Doctor

Contact

Family History

Father

Alive/Deceased/Unknown

Diabetes

High Blood Pressure

High Cholesterol

Cancer

Other

Father’s Mother

Alive/Deceased/Unknown

Diabetes

High Blood Pressure

High Cholesterol

Cancer

Other

Father’s Father

Alive/Deceased/Unknown

Diabetes

High Blood Pressure

High Cholesterol

Cancer

Other

Mother

Alive/Deceased/Unknown

Diabetes

High Blood Pressure

High Cholesterol

Cancer

Other

Mother’s Mother

Alive/Deceased/Unknown

Diabetes

High Blood Pressure

High Cholesterol

Cancer

Other

Mother’s Father

Alive/Deceased/Unknown

Diabetes

High Blood Pressure

High Cholesterol

Cancer

Other

Siblings

Alive/Deceased/Unknown

Diabetes

High Blood Pressure

High Cholesterol

Cancer

Other

Social History

Covid Screening

Shortness of breath

Yes No

Fever

Yes No

Cough

Yes No

Headache

Yes No

Runny Nose

Yes No

Sore Throat

Yes No

Nasal Congestion

Yes No

Positive COVID test within the past 10 days

Yes No

Pending/Planned COVID Testing/Results

Yes No

Contact with any person known or suspected to be in contact with COVID?

Yes No

Tobacco Use

Are you a

Current smoker Former smoker Nonsmoker E-Cigarette smoker

If Former Smoker, what year did you quit?

If current smoker

If How Often do you smoke cigarettes?

Everyday Some days, but not every day

How many cigarettes a day do you smoke?

5 or less 6-10 11-20 21-30 31 or more

How soon after you wake up do you smoke your first cigarette?

Within 5 minutes 6-30 minutes 31-60 minutes after 60 minutes

Are you interested in quitting?

Ready to quit thinking about quitting Not ready to quit

Drug/Alcohol

Drugs

Have you used drugs other than those for medical reasons in the past 12 months?

Yes No

Cocaine

Marijuana

Methamphetamine

Other

If other, please specify.

How many months since you last used?

Are you in a treatment program?

Have you ever injected drugs?

Are you still using?

Alcohol

Did you have a drink containing alcohol in the past year?

How often did you have a drink containing alcohol in the past year?

Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week

How many drinks did you have on a typical day when you were drinking in the past year?

1 / 2 drinks 3 or 4 drinks 5 or 6 drinks 7 to 9 drinks 10 or more drinks

How often did you have 6 or more drinks on one occasion in the past year?

Never Less than monthly Monthly Weekly Daily or almost daily

Sexual

Have you had sex in the past 12 months (vaginal, oral, anal)?

Yes No

With Men Only

Women only

Both Men and Women

Did you use protection

Yes No

How Often did you use protection?

All of the time Most of the time Half the time Some of the time

Have you ever had a sexually transmitted disease?

Yes No

Chlamydia

Gonorrhea

Syphilis

Herpes

Other

Miscellaneous

Do you have Children?

Yes No

Where are you originally from?

How long have you lived in the DFW Areas?

Review of Systems

Please select all that apply:

General Constitutional

Allergy/Immunologic

Ophthalmologic

ENT

Endocrine

Respiratory

Breast

Cardiovascular

Gastrointestinal

Hematology

Women Only

Men Only

Genitourinary

abdominal pain/swelling

blood in the urine

difficulty urinating

frequent urination

heavy uterine bleeding

kidney problems

loss of urine with cough or laughter

pain in lower back

painful urination

Musculoskeletal

Peripheral Vascular

absent pulses in feet

absent pulses in hands

blanching of skin

blood clots in legs

cold extremities

decreased sensation in extremities

pain/cramping in legs after exertion

painful extremities

ulceration of feet

Skin

Neurologic

Psychiatric

Your information will be encrypted.

Medical History

Cancer Screening

Diabetes Screening

Prior Hospital Admissions

Previous Surgical History

Current Medication

Family History

Social History

Covid Screening

Tobacco Use

Drug/Alcohol

Review of Systems

General Constitutional

Allergy/Immunologic

Ophthalmologic

ENT

Endocrine

Respiratory

Breast

Cardiovascular

Gastrointestinal

Hematology

Women Only

Men Only

Genitourinary

Musculoskeletal

Peripheral Vascular

Skin

Neurologic

Psychiatric