Highland Springs Primary Care
Patient History
Today’s Date: ____________
Patient Name: ______________________________
Date of Birth: _________________ Sex: □ Male □ Female
Phone Number: (home) _______________ (work) ______________ (cell) ___________________
Best number to reach you? ________________
Past Medical History
Check any illnesses or conditions you have had:
□ Anemia □ Depression □ Heart disease □ Nervous disorder □ Thyroid
□ Anxiety □ Diabetes □ High blood pressure □ Pneumonia □ Tuberculosis
□ Asthma/Bronchitis □ Emphysema □ Jaundice/Liver Problems □ STD’s □ Other:_____________
□ Bleeding tendency □ Epilepsy □ Kidney problems □ Stroke ____________________
□ Cancer___________ □ Glaucoma □ Migraines □ Substance Abuse ____________________
Past Surgical History
Check any past surgeries you have had:
□ Appendectomy □ Coronary Stent □ Kidney Surgery □ Wisdom Teeth
□ Carotid Endarterectomy □ C-Section □ Lap band □ Other:____________________
□ Cholecystectomy □ Gastric Bypass □ Orthopedic _____________________
□ Colon Surgery □ Hysterectomy □ Tonsillectomy _____________________
□ Coronary Artery Bypass Graft (CABG)
Date of Last Colonoscopy: ____/____/______ Date of Last DEXA: ____/____/______
Please list current MEDICATIONS with dosing (including nonprescription meds, vitamins, and
supplement
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Please list any ALLERGIES to medications, latex, or any other substances:
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Social History
Occupation: _____________________________ How long: _________
Marital Status: □ Married □ Divorced □ Single □ Widowed
Do you Exercise? □ yes □ no #:______ per Day / Week / Month
Do you use: Tobacco: □ yes □ no #/day:______ years of use_______
Alcohol: □ yes □ no #/day:______ years of use_______
Caffeine: □ yes □ no #/day:______ years of use_______
Illegal Drugs: □ yes □ no #/day:______ years of use_______
Education Level: _____________________________
Where and When have you lived or traveled outside of the U.S. or Canada:
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Mother: □ Living □ Deceased
Father: □ Living □ Deceased
Brothers: # Living ____ # Deceased _____
Sisters: # Living ____ # Deceased _____
Do you have any children? □ yes □ no
If yes, please list date of birth, age, and gender:
Check the disease against which you have been immunized:
□ Smallpox □ Tetanus □ Typhoid □ Polio □ Influenza □
Other:________________________________________________________________________________
Family History
Check illnesses which have occurred in any of your BLOOD RELATIVES:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Family Member Type Family Member
□ Allergy ___________________________ □ Bleeding tendency ________________
□ Cancer ___________________________ □ Diabetes ________________
□ Heart disease ________________ □ High blood pressure ________________
□ Kidney disease ________________ □ Nervous illness ________________
□ Tuberculosis _______________□ Other ___________________________________________________
Reproductive History (if applicable)
Onset of last menstrual cycle: ___________ Periods are: □ Regular □ Irregular □
Other:________________________________________________________________________________
Number of pregnancies: _____ Number of miscarriages: _____________________________
Current contraceptive: ___________________________