Patient Medical History

Patient Last Name

Patient First Name

Patient Middle Initial

Patient Date of Birth

Patient Occupation

Patient Reason for Visit

Please Note: If there aren't enough spaces, bring additional information with you at time of appointment.

Allergies (Include mediations, foods, xray dyes, etc.)

No Known Allergies

Name of Allergen

Type of Reaction

Approximate Date

Name of Allergen

Type of Reaction

Approximate Date

Name of Allergen

Type of Reaction

Approximate Date

Name of Allergen

Type of Reaction

Approximate Date

Name of Allergen

Type of Reaction

Approximate Date

Current Medications (Include prescription, over the counter, and herbal medications.)

No Medications Taken

Name of Medication

Dose (mg)

How Often Taken

Reason for Taking

Name of Medication

Dose (mg)

How Often Taken

Reason for Taking

Name of Medication

Dose (mg)

How Often Taken

Reason for Taking

Name of Medication

Dose (mg)

How Often Taken

Reason for Taking

Name of Medication

Dose (mg)

How Often Taken

Reason for Taking

Name of Medication

Dose (mg)

How Often Taken

Reason for Taking

Name of Medication

Dose (mg)

How Often Taken

Reason for Taking

Prescribing Pysician

Pharmacy (list pharmacy most frequently used for prescriptions)

Pharmacy Address

Pharmacy Phone Number

Previous Hospitalizations (Include all non-surgical hospitalizations.

No Hospitalizations

Reason for Hospitalization

Date of Hospitalization

Hospital or City

Reason for Hospitalization

Date of Hospitalization

Hospital or City

Reason for Hospitalization

Date of Hospitalization

Hospital or City

Surgeries (Include all surgery in your lifetime.)

No Surgeries

Reason for Surgery

Date of Surgery

Hospital or City

Reason for Surgery

Date of Surgery

Hospital or City

Reason for Surgery

Date of Surgery

Hospital or City

Tobacco History

Are you an active cigarette smoker?

Yes

Have you ever been a cigarette smoker?

Yes

If yes how many packs a day?

For how many years?

I quit in what year?

Do you use any other tobacco products?

Yes

If yes, what kind?

Alcohol and Drug History

Have you ever been diagnosed with Alcoholism?

Yes

Do you currently drink regularly?

Yes

If yes to drinking regularly, how many drinks per week? (beer, wine, or liquor)

Have you ever used intravenous drugs?

Yes

Medical Related Issues

Have you ever had Diabetes Mellitus?

Yes

If yes, what kind (check all that apply)

Diet Controlled

Insulin Dependent

Oral Agents

Pregnancy Related

Date of Diagnosis

Hypertension

Yes

Do you take medication for this?

Yes

Defined by persistent Systolic >140 Diastolic >80

Yes

Date of Diagnosis

High Cholestoral

Yes

Do you take Medication for this?

Yes

Date of Diagnosis

Low Back Pain

Yes

Do you always have this pain?

Yes

Have you seen a doctor for this pain?

Yes

If so when?

Arthritis/Join Pain

Yes

If so, location

Hips

Shoulders

Hands

Knees

Feet

Neck

Back

Date of Diagnosis

Asthma/Breathing Problems

Yes

Date of Diagnosis

Have you ever had to spend a night in the hospital because of asthma or breathing problems?

Yes

In the last 12 months have you taken prednisone because of asthma?

Yes

In the last 12 months have you missed school or work because of asthma or breathing problems?

Yes

Do you get short of breath on exertion?

Yes

Do you get short of breath walking on a flat surface?

Yes

Do you get short of breath climbing stairs?

Yes

Gastroesophageal Reflux (heartburn)

Yes

Date of Diagnosis

Sleep Apnea

Yes

Date of Diagnosis

Do you snore?

Yes

Do you frequently wake up at night?

Yes

Have you ever had a sleep study?

Yes

If so when?

Do you use a CPAP or BIPAP machine?

Yes

Have you been told you stop breathing while asleep?

Yes

Urinary Incontinence

Yes

Date of Diagnosis

Do you experience leaking of urine?

Yes

Depression

Yes

Date of Diagnosis

Do you take medication for this?

Yes

Have you seen a therapist in the past?

Yes

If yes, who did you see?

Please check the following that apply to you

General:

Are you fatigued or tired?

Do you have fever/chills?

Do you have a headache?

Have you been abnormally losing weight?

Have you been abnormally gaining weight?

Eyes:

Are you having difficulty seeing?

Have you been diagnosed with Glaucoma?

If so when?

Head/Ears/Nose/Throat

Do you have dry mouth?

Do you have hearing problems?

Are you suffering from hoarseness?

Do you have lumps/swelling in the neck?

Do you have a sore throat?

Are you having troubles swallowing?

Cardiac (Heart)

Do you have chest pain?

Do you have an irregular heartbeat?

Do you have heart pain with walking?

Do you suffer from shortness of breath?

Do you have swelling in the feet/ankles?

Do you have a heart murmur?

Do you have a pacemaker?

Do you suffer from blood clots?

Have you ever had a heart attach?

If so when?

Have you ever had a stroke?

If so when?

Neuro

Do you suffer from dizziness?

Do you/have you fainted?

Do you suffer from headaches?

Do you suffer from memory loss?

Do you suffer from numbness?

If so where?

Do you suffer from weekness?

Respiratory

Do you cough more than normal?

Do you have shortness of breath?

Do you inhalers?

If so which one?

Do you suffer from wheezing?

Gastro-Intestinal

Do you have abdominal pain?

Do you have blood in your stool?

Have you had a change in bowel habits?

Are you constipated?

Do you have heartburn?

Do you have a loss of appetite?

Do you suffer from heartburn?

Do you have a loss of appetite?

Are you nauseated?

Have you been vomiting?

Have you ever had gallstones?

If so when?

Males Only

Do you have blood in your urine?

Do you have difficulty achieving an erection?

Do you have a foul odor in your urine?

Do you have pain in your testicles?

Do you have trouble urinating?

Females Only

Do you have breast discomfort?

Do you have irregular bleeding?

When was your last menstrual cycle?

Is intercourse painful for you?

Do you have post-menopausal bleeding?

Do you have trouble urinating?

Do you have vaginal discharge?

Musculoskeletal

Do you have back pain?

Do you have joint pain?

Do you have muscle pain?

Do you have swelling in any joints?

Skin/Hair/Nails

Do you have any bruising or do you bruise easily?

Do you suffer from hair loss?

Do you have any nail problems?

Do you have any rashes?

If so where?

Have you seen any changes in your skin lately?

Mental Health

Do you suffer from anxiety?

Do you suffer physical/mental abuse?

Do you suffer from mood swings?

Do you suffer from stress?

Do you feel suicidal?

Abdomen/Pelvis

Have you had stomach ulcers?

If so when?

Have you had any intestinal blockage?

If so when?

Have you had/have kidney disease?

If so when were you diagnosed?

Are you on dialysis for kidney disease?

Have you had a bladder infection?

If so when?

Have you had an urinary tract infection?

If so when?

Have you had kidney stones?

If so when?

Have you had/have liver disease? Cirrhosis?

If so when were you diagnosed?

Have you ever had pancreatitis?

If so when?

Sexually Transmitted Diseases

Have you ever been diagnosed with Hepatitis?

If so when?

Have you ever been tested or diagnosed with HIV?

If so when?

Cancer

Have you ever been diagnosed with cancer?

If so when?

What type of cancer where you diagnosed with?

Recent Tests/Health Maintenance Dates

Bone Density

Colonoscopy

Diabetic Foot Exam

Eye Exam

Mammogram

Pap Smear

Physical

PSA

Tetanus Shot

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