Chabot Student Health and Wellness Center
Affiliated with Valley Care Health System
New Patient Confidential Medical History
NAME: _______________________________________________________Age___________D.O.B_______________Date:_________________
Medications: List any medicines you take regularly, including over the counter medications or supplements:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Allergies: Medications, latex, food, insects etc.: Yes___No___ please list: ______________________________________________
Social History:
Caffeine: No: ____Yes: ____ (cups/day) ________________
Alcohol: No: _____Yes: ____ How many drinks per day_______ per week_______per month_______
Recreation drugs: No: ____Yes: ____ which kind: ___________________________________
Tobacco: No: ____Yes: ____ Pack/day: ________ cigarettes/day: ________cigarettes/week: ________cigars_______Other:_________
Exercise: No: ____Yes: ____ Days/week: _________
Personal Medical History: (Please mark the following as it applies to you):
Allergies (seasonal)
Anemia
Asperger’s
Asthma
Autism
Anxiety
Blood Disorder
Chicken Pox
Diabetes
Headaches
Head Injury or Concussion
Heart Problems
High Blood Pressure
High Cholesterol
Heart Murmur
Depression
Kidney Disease
Hepatitis: Type?
Muscle or Joint Problems
Liver Disease
Lung Disease
Seizure
Skin Disorder
Sexually Transmitted Infection
Stomach Problem
Thyroid Problem
Tuberculosis
Alcohol or Drug Problems
Eating Disorder
History of MRSA infection
G6PD Deficiency
Other
Please explain any items you have checked above and date of occurrence: ______________________________________________________________
Hospitalizations and Surgeries (with reasons and dates):__________________________________________________________________________
Family Medical History:
(Please mark the following if there is a history in your immediate blood relatives, e.g. parents, siblings or grandparents)
Relationship
Relationship
Breast Cancer
Heart Disease
Alcoholism
Colon Cancer
High Cholesterol
Suicide/Depression
Other Cancer
Diabetes
Mental Illness
High Blood Pressure
Asthma/Hay Fever
Family Violence
Stroke/Blood Clots
Thyroid Disease
Other
Relationship
Immunization History:
Date of last Tetanus shot: ______________ Hepatitis B shot: _______________MMR shot: _________________Varicella shot: ________________
Date of last TB Test: ___________________ Result: _______________
Women’s Health History ONLY:
Date of last menstrual period: ____________________ History of STD? No: ____Yes: ____ If yes, what & when? ___________________________
Have you had HPV vaccine? No: ____Yes: ____ Don’t Know If yes, when? _______________________________
Method of birth control: _________________________________
Have you ever been pregnant? No: ____Yes: ____ If Yes, how many? _____ Live Birth? _____ Miscarriages_____ Abortion _______
Date of last pap? Month_______ Year_______ Result: Normal or Abnormal Do you do self breast exam No: ____Yes: ____
Men’s Health History ONLY:
Do you do self testicular exam? No: ____Yes: ____
Method of birth control: Condoms: _______ Withdrawal: _______Other:______ Partner: Pill/Path/Ring/Depo N/A
History of STD? No: ____Yes: ____ If yes, what & when? ___________________________
________________________________________________________
________________________
Student’s Signature
Date
REVIEWED BY CLINICIAN
Clinician Name & Signature: _______________________________________________
Date: ______________________
Clinician Name & Signature: _______________________________________________
Date: _______________________
Medical Hx Form 7/2013