Medical History Questionnaire

Name

Date of Birth

Preferred Name

Sex

Emergency Contact

Phone #

Are you transferring from another medical practice?

Yes No

If yes, please list their practice name, address, and phone number

Testing: Please check all that apply along with the date/place

Colonoscopy

Date

Facility

Hearing Test

Date

Facility

Rectal Exam

Date

Facility

Fasting Labs

Date

Facility

Mammogram

Date

Facility

Bone Density Scan

Date

Facility

Pap Smear

Date

Facility

Flu Shot

Date

Facility

Pneumonia Shot

Date

Facility

Tetanus Shot

Date

Facility

Shingles Shot

Date

Facility

Add new row

Have you ever had surgery?

Yes No

If yes, please be specific and include the date/place

Add new row

Do you have any allergies to medications?

Yes No

If yes, please list

Have you ever been diagnosed with any medical conditions?

Yes No

If yes, please list below:

Add new row

Family History:

Mother

Alive Deceased

Cause of death?

Mother’s Medical Problems

Father

Alive Deceased

Cause of death?

Father’s Medical Problems

Marital status

Single Married Divorced Widowed Separated Other

Specify

Who do you live with?

Alone

Parents

Spouse

Family Member

Significant other

Friend

Roommate

Other

Specify

Employment status

Employed Unemployed Disabled Retired Student Homemaker Other

Name of employer

Specify

Do you have any children?

Yes No

If yes, how many?

Tobacco use

Never Former Current

Tobacco Type

Chew

Cigarettes

Vape

Alcohol use

Never Former Frequently Occasionally Rarely

Recreational Drug use

Never Former Frequently Occasionally Rarely

Recreational Drugs used

Medical Marijuana

Never Former Frequently Occasionally Rarely

Optional:

Primary Language

Race

Sexual Preference

Blood Type