PATIENT MEDICAL HISTORY FORM
PATIENT NAME: ___________________________________________________
CHIEF COMPLAINT: What is the main reason for your visit today?
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Please answer the following questions about your present medical problem as it applies to you.
PAST MEDICAL HISTORY: Please check all that apply:
□ Cancer
□ Lymphoma
□ Leukemia
□ Blood Problem
□ Rheumatologic Disease
□ High Blood Pressure
□ Thyroid Problems
□ High Cholesterol
□ Diabetes
□ Kidney Disease
□ Tuberculosis
□ Asthma
□ Heart Disease
□ Arthritis
□ COPD/Lung Disease
□ Other ____________________________________
PAST SURGICAL HISTORY: Please check all that apply and list date:
□ Appendectomy (Appendix) ____________
□ Cataract Removal ___________________
□ Breast Augmentation _________________
□ Cholecystectomy (Gall bladder) ________
□ Breast Biopsy ______________________
□ Coronary Artery Bypass ______________
□ Breast Mastectomy___________________
□ Hysterectomy Total __________________
□ Hysterectomy Partial__________________
□ Inguinal Hernia_____________________
□ Laminectomy ______________________
□ Prostatectomy (Prostate) ______________
□ Splenectomy (Spleen) ________________
□ Thyroidectomy _____________________
□ Tonsillectomy ______________________
□ Colon Surgery______________________
□ Other _____________________________
If you have had cancer, have you ever received chemotherapy or radiation: ____Yes ____No if so, explain:
____________________________________________________________________________________________
____________________________________________________________________________________________
P: CCC Forms/Front Office/New Patient Forms
Revised 6/18/2014
1
MEDICATIONS:
List all medications, or drugs you currently use or have used at home within the last three months. Include those with a prescription from a doctor,
those you bought over the counter in a store, any you received from a friend, any vitamins, home remedies, laxatives or any other product you take to
improve your health. If you do not know all this information, please bring all the bottles or boxes with you to your next office visit. (Please attach an
additional page if you need more space).
Name & Strength of Medication
Amount taken
Approximate date started
1. _____________________________________________________________________________________________
2.
_____________________________________________________________________________________________
3.
_____________________________________________________________________________________________
4.
_____________________________________________________________________________________________
5.
_____________________________________________________________________________________________
6.
_____________________________________________________________________________________________
7.
______________________________________________________________________________________________
Medication Allergies:
List anything medications you are allergic to:
Item
Describe reaction you had
1. ________________________________________________________________________________________________
________________________________________________________________________________________________
2.
________________________________________________________________________________________________
________________________________________________________________________________________________
3.
________________________________________________________________________________________________
________________________________________________________________________________________________
4.
________________________________________________________________________________________________
________________________________________________________________________________________________
FOR WOMEN ONLY
1. Approximately how old were you when you started having menstrual periods? ______________
2. Which statement describes you?
□
□
□
□
□
I am still having regular periods.
My periods are irregular.
I am pregnant.
My periods have stopped on their own (menopause). Age___________
I have had an operation which stopped my periods.
□ One ovary only
□ Both ovaries
□ Other
□ Uterus only
□ Uterus and one ovary
□ Uterus and both ovaries
3. Number of pregnancies ____________________
Number of children born alive______________
Number of miscarriages___________________
4. Are you or have you ever been on hormone replacement (estrogen/progesterone)? Please explain_______________________________________
P: CCC Forms/Front Office/New Patient Forms
Revised 6/18/2014
2
The following questions are about your FAMILY, you may not know all the information asked. Please answer to the best of your ability.
Mother _______
_________
Please add additional information on the last page.
PRESENT AGE
HEATH PROBLEMS
OR AGE AT DEATH
________________
__________________________
Father
_______
_________
________________
__________________________
_______________________________
Brother _______
_________
________________
__________________________
_______________________________
LIVING
DECEASED
CAUSE OF DEATH
IF DECEASED
_______________________________
Brother _______
_________
________________
__________________________
_______________________________
Brother _______
_________
________________
__________________________
_______________________________
Sister
_______
_________
________________
__________________________
_______________________________
Sister
_______
_________
________________
__________________________
_______________________________
Sister
_______
_________
________________
__________________________
_______________________________
CHILDREN:
First
NUMBER OF CHILDREN: __________________
_______
_________
_________________
___________________________
________________________________
Second _______
_________
_________________
___________________________
________________________________
Third
_______
_________
_________________
___________________________
________________________________
Fourth
_______
_________
_________________
___________________________
________________________________
Fifth
_______
_________
_________________
___________________________
________________________________
Any history of cancer, leukemia, or lymphoma in your family? If so, give details: _____________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
SOCIAL HISTORY:
Marital Status Circle One: Single
Married
Divorced
Widowed
Partnered
Are you working? ________________
What is/was your job position? ______________________________________________________________________________________________
What are your hobbies? ___________________________________________________________________________________________________
Have you EVER smoked? _______________________
Do you smoke now? ___________________________
If yes, average number of packs per day? ____________________________
Number of years smoked?
____________________________
Date stopped? ____________________________
Do you desire counseling for smoking cessation? ________
Do you consume alcoholic drinks? _______________________
If yes, how often?
____________________________
Do you now or have you ever had a problem with alcoholism or drug addiction? _______________________________________________________
If you are of reproductive age, do you desire to address fertility in regard to your diagnosis and treatment options? _________________________
P: CCC Forms/Front Office/New Patient Forms
Revised 6/18/2014
3
Review of Systems: Do you CURRENTLY have or are you NOW bothered with the following symptoms? Circle Yes or No
Constitutional Symptoms
Fever
Chills
Fatigue/Excessively Tired
Weight Loss
Allergic/Immunologic
Seasonal allergies
Food allergies
IV contrast allergies
Drug allergies
Eyes
Excessive tearing
Eye irritation
Double vision/Blurred vision
Ear/Nose/Throat/Mouth
Hearing difficulty
Dry mouth
Mouth irritation
Sore throat/Hoarseness
Difficulty Swallowing
Ear discomfort
Sinus problem
Ringing in the ears
Endocrine
Hot flashes
Sweats
Heat intolerance
Cold intolerance
Excessive thirst
Hematological/Lymphatic
Easy bruising
Easy bleeding
Tender lymph nodes
Swollen lymph nodes
Breasts
Abnormal breast mass
Nipple discharge
Nipple pain
Respiratory
Wheezing
Persistent cough
Sputum production
Shortness of breath
Chest pain on breathing
Coughing up blood
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
N
N
N
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Cardiovascular
Heart pain (Angina)
Irregular heart rhythm
Congestive heart failure
Varicose veins
Extremity swelling
Gastrointestinal
Nausea
Vomiting
Diarrhea
Constipation
Abdominal pain
Abdominal swelling
Loss of appetite
Indigestion/heartburn
Blood in bowel movement
Genitourinary
Blood in urine
Painful urination
Frequent urination
Hesitation on urination
Incontinence
Sexual dysfunction
Genital Mass/tenderness
Musculoskeletal
Joint pain
Swelling/edema
Muscle aches
Bone pain
Decreased range of motion
Integumentary
Skin rash
Lesions
Skin breakdown
Persistent itch
Neurological
Headaches
Dizzy spells
Numbness/tingling
Weakness
Unsteady balance when walking
Tremor
Psychological
Are you generally satisfied with your life?
Do you feel nervous or anxious?
Do you have trouble sleeping?
Do you have periods of extreme sadness or crying?
Y
Y
Y
Y
Y
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Y
Y
Y
Y
N
N
N
N
The above is true and correct to the best of my knowledge.
Patient Signature: ____________________________________________
Physician Signature: ________________________________________
Date: _______/________/________
P: CCC Forms/Front Office/New Patient Forms
Revised 6/18/2014
4