Medical History
*Please (√) symptoms you currently have*
General
□Chills
□Depression/Nervousness
□Dizziness/Fainting
□Fever
□Forgetfulness
□Headache
□Loss of Sleep
□Loss of Weight
□Numbness
□Sweats
□Other: __________
Muscle/Joint/Bone
Skin
Pain, weakness, numbness in:
□Bruise Easy
□Sores won’t heal
□Arms
□Hips
□Hives
□Itching/Rash
□Back
□Legs
□Change in Moles
□Scars
□Feet
□Hands
□other: ______
□Neck
□Shoulders
Gastrointestinal
□Appetite Poor
□Gas
□Vomiting
□Bloating/Pain
□Hemorrhoids
□Excessive Thirst
□Bowel Changes
□Indigestion
□Diarrhea
□Constipation
□Nausea
□Rectal Bleeding
Eye/Ear/Nose/Throat
□Bleeding Gums
□Blurred Vision
□Crossed Eyes
□Difficulty Swallowing
□Double Vision
□Earache/Discharge
Pt. Name______________________________
1
Medical History (cont’d)
Pt. Name: _________________________
□Hay Fever
□Hoarseness
□Loss of Hearing
□Nosebleeds
□Persistent Cough
□Ringing in Ears
□Sinus Problems
□Vision-Flashes/Halos
□other: _____________
Cardiovascular
Genito-urinary
□Chest Pain
□Blood in Urine
□High/Low Blood Pressure
□Frequent Urination
□Irregular/Rapid Heart Beat
□Lack of Bladder Control
□Poor Circulation
□Painful Urination
□Swelling Ankles
□Other:________________
□Varicose Veins
□Other:_______________
Men Only
Women Only
□Erection Difficulties
□Abnormal Pap smear
□Lump in Testicle
□Bleeding between Periods
□Penis Discharge
□Breast Lump
□Sore on Penis
□Extreme Menstrual Pain
□Other:________
□Hot Flashes
Women Only (cont’d)
□Nipple Discharge
Date of Last Menstrual Cycle:
□Vaginal Discharge
/
/
□Other: ___________________
Date of last Pap smear:
Have you had a mammogram?
Are you Pregnant?
□Yes
□Yes
□No
/
/
□No
Date:______/_____/______
Number of Children:
2
Pt. Name: __________________________________________
Medical History (cont’d)
*Check (√) conditions you have had or currently have.*
□AIDS
□Chicken Pox
□HIV Positive
□Polio
□Appendicitis
□Diabetes
□Kidney Disease
□Prostate Problem
□Arthritis
□Emphysema
□Liver Disease
□Rheumatic Fever
□Asthma
□Epilepsy
□Measles
□Scarlet Fever
□Bleeding Disorders □Glaucoma
□Migraine Headaches
□Breast Lump
□Heart Disease
□Multiple Sclerosis □Thyroid Problem
□Cancer
□Hepatitis
□Mumps
□Tuberculosis
□Cataracts
□Herpes
□Pacemaker
□Ulcers
□Chemical Dependency
□High Cholesterol
□Pneumonia
□Stroke
□Venereal Disease
□Other: ___________________________________________________________
Surgeries/Hospitalization
•Please list surgeries/hospitalizations and approx. mo/yr:
1. _______________________
2. _______________________
3. _______________________
4. _____________________
5. _____________________
6. _____________________
Medications
Please list all medication you are currently taking including vitamins/supplements:
Name
Strength
Dose
________________________________________________________
________________________________________________________
Pharmacy Name: ___________________________________________
Address: _____________________ City: ____________ Zip: _______
Phone Number: (____) _______-_________
3
Medical History (cont’d)
Allergies
Medication
Reaction
Date
_________________________________________________
_________________________________________________
_________________________________________________
Social History
Are you sexually active?
□Yes
□ No
If yes, what age did you become sexually active? ________
Do you drink alcoholic beverages?
□Yes
□No
If yes, How much? _______________ How often? ________
Do you smoke?
□Yes
Have you ever been a smoker?
□No
□Yes
□No
How much? ____________ packs/day
To the best of my knowledge, the above information is complete and correct. I understand
that it is my responsibility to inform my doctor if I, or my child, ever has a change in health.
_____________________________________________
Signature of Patient, Parent, Guardian or Representative
______________________________
____/_____/_____
Date
_______________________
Print Name of Patient
Relationship to Patient
4