Medical History

Image

For office use/comment

Name

Date of Birth

Height

Weight

Reason for Visit

CURRENT MEDICAL HISTORY

For office use/comment

PAST MEDICAL HISTORY

For office use/comment

PAST SURGICAL HISTORY

Add Additional Surgeries

PAST PROCEDURE HISTORY

If yes, Date

FAMILY HISTORY OF CANCERS

Yes

Colon cancer/polyps (Z80.0)

Yes No

Relationship

Age when Diagnosed

Stomach Cancer(Z80.0)

Yes No

Relationship

Age when Diagnosed

Pancreatic Cancer

Yes No

Relationship

Age when Diagnosed

Liver Cancer (Z80.0)

Yes No

Relationship

Age when Diagnosed

Breast Cancer

Yes No

Relationship

Age when Diagnosed

Ovary Cancer

Yes No

Relationship

Age when Diagnosed

Uterine Cancer

Yes No

Relationship

Age when Diagnosed

Cervical Cancer

Yes No

Relationship

Age when Diagnosed

Liver Disease

Yes No

Relationship

Age when Diagnosed

Ulcerative Colitis

Yes No

Relationship

Age when Diagnosed

Celiac Disease

Yes No

Relationship

Age when Diagnosed

Crohn’s Disease

Yes No

Relationship

Age when Diagnosed

Add Additional Condition

HOSPITALIZATION HISTORY (Recent inpatient/ER visit)

MEDICATION LIST

Medication

Dose

How Often?

Medication

Dose

How Often?

Medication

Dose

How Often?

Medication

Dose

How Often?

Add more medication

SOCIAL HISTORY

Smoking?

Yes No

How much?

Number of Years

If Quit, When?

How Often?

Alcohol?

Yes No

How much?

Number of Years

If Quit, When?

How Often?

Drugs

Yes No

How much?

Number of Years

If Quit, When?

How Often?

Recent Travel

Yes No

If yes, where?

ALLERGIES

Latex

Yes No

Dye

Yes No

Food

Yes No

If food, please specify

Medication Allergies

YOUR HEALTHCARE PROVIDERS

Family Doctor

Cardiologist

Lung Specialist

Other

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Patient Signature

Date

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