Patient Medical History

Patient Name:

Date of Birth:

Height:

Weight:

Medication Allergies(List down):

List all medications you are currently taking(including prescriptions, over-the-counter meds., vitamins and herbals):

Do you know, or have you ever had disease or conditions of: (Please choose YES or NO)

LUNGS

History of Tuberculosis

Yes No

CARDIOVASCULAR

Defibrillator

Yes No

Pacemaker

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

SKIN

Tanning Bed Use

Yes No

Skin Cancer

Yes No

FAMILY HISTORY

Skin Cancer

Yes No

If so, who:

OTHER SYSTEMIC

Diabetes

Yes No

Thyroid

Yes No

HIV

Yes No

Hepatitis

Yes No

Type:

A B C

Organ Transplant

Yes No

Organ:

Year:

Joint Replacement

Yes No

Joint:

Year:

Cancer (not of skin)

Yes No

Type:

Year:

Kidney

Yes No

Problem:

Bladder

Yes No

Problem:

Prostate

Yes No

Cancer:

Stomach

Yes No

Problem:

Glaucoma

Yes No

Cochlear Implant

Yes No

Lymphoma

Yes No

Leukemia

Yes No

WOMEN'S HEALTH

Pregnant

Yes No

Due Date:

Planning Pregnancy:

Yes No

SOCIAL HISTORY

Do you drink alcohol?

Yes No

If Yes, How many drinks per day?

Do you use IV/recreational drugs?

Yes No

If Yes, what kind of drugs?

How often?

Smoking status

Never Smoked Former Smoker Current Smoker

When did you have your last?

Colonoscopy Date:

Flu Vaccine Date:

Pneumonia Vaccine Date:

Women:

Mammogram Date:

Pap Smear Date:

Other Diseases or Conditions:

Occupation:

Hobbies:

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Signed by Patient/Parent or Guardian:

Date:

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