Texas Familicare Medical Group
1725 Chadwick Court, Suite 100
Hurst, Texas 76054
Patients Name:_______________________________________________
Date of Birth:_________________________________________________
Today’s Date:_________________________________________________
FAMILY HISTORY
IF ANY BLOOD RELATIVE HAS SUFFERED ANY OF THE FOLLOWING
PLEASE CIRCLE AND INDICATE WHICH RELATIVE: M, F, B, S, GM, GF
1)
2)
3)
4)
5)
EPILEPSY
MIGRAINES
MENTAL ILLNESS
GLAUCOMA
DIABETES
6) THYROID DISEASE
7) HAYFEVER
8) ASTHMA
9) ANEMIA
10) BLEEDS EASILY
11) OSTEOPOROSIS
12) ARTHRITIS
13) HEART DISEASE
14) STROKE
15) HYPERTENSION
16) LIPID DISORDER
17) ALCOHOLISM
18) HEPATITIS
19) CANCER
20) OTHER____________
PATIENT’S MEDICAL HISTORY
HOSPITAL ADMISSIONS (NOT INCLUDING PREGNANCIES)
YEAR
ILLNESS OR OPERATIONS
TEST / EXAM
LIST ALL MEDICATIONS YOU ARE TAKING INCLUDING:
NAME, DOSAGE AND FREQUENCY
1) __________________________________________
2) __________________________________________
3) __________________________________________
4) __________________________________________
5) __________________________________________
COLONOSCOPY
YEAR
RECTAL / STOOL
CHOLESTEROL
EYE EXAM
PSA / MALE EXAM
VACCINES
YEAR
TETANUS / TD
INFLUENZA (FLU)
PNEUMONIA
HEPATITIS
DO YOU HAVE OR EVER HAD ANY OF THE FOLLOWING: CIRCLE
EAR INFECTION-FREQUENT
EYE PAIN
FAILING VISION
DOUBLE OR BLURRED VISION
DECREASED HEARING
FRACTURE OR DISLOCATION
HEAD INJURY
NECK INJURY
ARM INJURY
HAND OR WRIST INJURY
SHOULDER INJURY
ELBOW INJURY
RIB INJURY
BACK INJURY
LEG INJURY
FOOT OR ANKLE INJURY
MUSCLE DISORDER
AIDS/HIV POSITIVE
ALCOHOLISM
DRUG ADDICTION
VENEREAL DISEASE
EPILEPSY
CONVULSIONS
SKIN DISORDER
NOSE BLEEDS-RECURRENT
MRSA
ABDOMINAL PAIN
TUBERCULOSIS
APPENDICITIS
ANOREXIA
DIVERTICULOSIS/CROHN’S/COLITIS
ANEMIA
BLOOD IN URINE
BLOOD DISORDER
SUGAR IN URINE
ASTHMA/WHEEZING
DIABETES
BRONCHITIS
BLOODY OR TARRY STOOL
CHRONIC COUGH
DIARRHEA/CONSTIPATION
ALLERGIES/HAY FEVER
KIDNEY PROBLEM
SINUS TROUBLE
HERNIA
SORE THROAT-FREQUENT
STOMACH ULCER
RHEUMATIC FEVER
CANCER
HEART TROUBLE
TUMOR / CYST
CHEST PAIN
ARTHRITIS
HIGH BLOOD PRESSURE
OSTEOMYELLITIS
HEADACHES
MYALGIA
DIZZY SPELLS
NEURITIS
FAINTING SPELLS
VERICOSE VEINS
DIFFICULTY SWALLOWING
HARDENING OF ARTERIES
NERVOUS DISORDER
TUBERCULOSIS
FEMALE
YEAR
WELL WOMENS
EXAM
MAMMOGRAM
PREGNANCIES
CHILDREN
FOOD OR DRUG
ALLERGIES
SMOKE
START
DRINK ALCOHOL
START
Y/N
STOPPED
Y/N
STOPPED