Medical History Questionnaire
Provider you are seeing today: _________________________________________________________________________________________
Patient’s Name: __________________________________________
Date of Birth: _________________
Date: __________________
Why are you here today? ______________________________________________________________________________________________
Who referred you? ___________________________________________________________________________________________________
Past Medical History:
Do you have or ever had any of the following conditions? Please check all that apply:
■ Acne
■ Easy Bruising Tendency
■ Obstructive Sleep Apnea
■ Acute Myocardial Infarction
(Heart Attack)
■ Edema
■ Osteoarthritis
■ Emotional Disturbance
■ Osteoporosis
■ Anxiety
■ Factor VII Deficiency
(Hemophilia)
■ Pain During Urination
■ Arthritis
■ Fainting (Syncope)
■ Asthma
■ Fibromyalgia
■ Autoimmune Disorder
(Lupus/Scleroderma)
■ Anemia (Low Blood Count)
■ Benign Polyps of The Large
Intestine (Colon Polyps)
■ Benign Prostatic Hypertrophy
(Enlarged Prostate)
■ Blood Transfusion
Complications
■ Breast Cancer
■ Pain When Defecating
(Bowel Movement)
■ Transient Ischemic Attack
(Mini Stroke)
■ Transient Limb Paralysis
■ Tuberculosis
■ Vaginitis
■ Varicose Veins
■ Gallbladder Disease
■ Peripheral Vascular Disease
(Poor Circulation Hands
and Feet)
■ Other:
■ Gastric Ulcer
■ Pneumonia
___________________________
■ Headache
■ Prostate Cancer
■ Heart Disease
■ Prostate Enlargement
■ Heartburn
■ Pulmonary Disease
(Lung Disease)
■ Hepatic Disease (Liver Disease)
■ Hepatitis
■ HIV Infection
■ Recent Methicillin-resistant
Staff (MRSA)
■ Vision Problems
___________________________
___________________________
___________________________
___________________________
■ Hypercholesterolemia
■ Red Blood in Bowel
Movement
■ Hypertension
■ Rheumatic Fever
■ Infection of Kidney
■ Rubella
■ Irritable Bowel Syndrome
■ Seizure Disorder
___________________________
■ Loss of Hearing
■ Sinusitis
___________________________
■ Colon Cancer
■ Lower Back Pain
■ Stroke Syndrome
■ Depression
■ Mitral Valve Disorder
■ Taking Aspirin
■ Diabetes Mellitus
■ Murmurs
■ Diverticulosis
■ Nephrolithiasis
(Kidney Stones)
■ Thromboembolic Disease
(Blood Clot Disorder)
■ Cancer
■ Chemotherapy Administration
■ Chest Pain (Angina)
■ Chronic Liver Disease
■ Chronic Obstructive
Pulmonary Disease
■ Dizziness
■ Obesity
■ Thrombophlebitis
■ Thyroid Disorder
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
■ No Past Medical History
Form 73087 (Rev. 05/08)
JG 08.2865
Hospitalization:
Hospitalization
Date
Reason for Hospitalization
________________________________________________
_________________
_____________________________________________
________________________________________________
_________________
_____________________________________________
________________________________________________
_________________
_____________________________________________
________________________________________________
_________________
_____________________________________________
Surgery
Date
Reason for Surgery
________________________________________________
_________________
_____________________________________________
________________________________________________
_________________
_____________________________________________
________________________________________________
_________________
_____________________________________________
________________________________________________
_________________
_____________________________________________
Surgery:
■ No Surgical or Hospitalization History
Family History:
Please check all that apply:
Indicate Family Member
Indicate Family Member
■ Alzheimer’s Disease
________________________
■ FH-Unattainable-Patient Adopted ________________________
■ Anemia
________________________
■ Heart Disease
________________________
■ Benign Polyps of The
Large Intestine (Colon Polyps)
■ Hepatic Disorder
________________________
________________________
■ Hypercholesterolemia
________________________
■ Bladder Cancer
________________________
■ Hypertension
________________________
■ Breast Cancer
________________________
■ Osteoporosis
________________________
■ Cancer
________________________
■ Ovarian Cancer
________________________
■ Cervical Cancer
________________________
■ Prostate Cancer
________________________
■ Chronic Bronchitis
________________________
■ Pulmonary Disease
________________________
■ Chronic Obstructive
Pulmonary Disease
________________________
■ Renal Disease
________________________
■ Colon Cancer
________________________
■ Sickle Cell Anemia
________________________
■ Diabetes Mellitus
________________________
■ Stroke Syndrome
________________________
■ Emphysema
________________________
■ Tay-Sachs Disease
________________________
■ Family Health Status
of Father - Deceased
Age: __________________
■ Thromboembolic Disease
(Blood Clot Disorder)
________________________
■ Uterine Cancer
________________________
■ Other: ______________________
________________________
■ Other: ______________________
________________________
■ Other: ______________________
________________________
Cause: __________________
■ Family Health Status
of Mother - Deceased
Age: __________________
Cause: __________________
■ No Family Medical History
Form 73087 (Rev. 05/08)
JG 08.2865
Social History:
Marital Status:
■ Married
■ Single
■ Widowed
■ Separated
■ Divorced
■ Life Partner
Children’s Ages: ______________________________________________________________________________________________________
Please check all that apply:
■ Alcohol Use
Alcohol Use/Week ______________
■ Drug Use (Recreational)
Explain: ___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
■ Using Intravenous Drugs
Explain: ___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
■ Previous History
of Smoking
Date Quit _____________________
Methods Used to Quit:____________________________________
Packs Per Day _________________
_______________________________________________________
Number of Attempts to Quit _______
_______________________________________________________
Years of Smoking_______________
■ No History of Smoking
■ Smoking a Pipe
Times per day__________________
How many years? ____________
■ Smoking Cigarettes
Packs Per Day __________________
How many years? ____________
■ Chew Tobacco (Chewing Times per day__________________
Nicotine-Containing Substances)
How many years? ____________
■ Cigars
Number per day________________
How many years? ____________
■ Exercise Habits
Times per week ________________
■ Wishing to Stop Smoking
■ Exercising Regularly
■ Being Sedentary (Do not exercise)
■ Sexually Active
■ Occupation
List All: ___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
■ Travel (Recently Out of
the Country)
Where? ___________________________________________________________________________________
__________________________________________________________________________________________
Do you have an advanced directive? ■ Yes ■ No
Form 73087 (Rev. 05/08)
JG 08.2865
Allergies:
Allergy
Reaction
________________________________________________
_________________________________________________________________
________________________________________________
_________________________________________________________________
________________________________________________
_________________________________________________________________
Medications:
Include vitamins, herbal supplements and over the counter medications
Medications
Dosage
Frequency
Reason for Taking
________________________________
_____________
_____________________
_________________________________________
________________________________
_____________
_____________________
_________________________________________
________________________________
_____________
_____________________
_________________________________________
________________________________
_____________
_____________________
_________________________________________
________________________________
_____________
_____________________
_________________________________________
________________________________
_____________
_____________________
_________________________________________
________________________________
_____________
_____________________
_________________________________________
■ Yes
Have you participated in any clinical trials or used experimental drugs?
■ No
Explain: _____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Are you pregnant? ■ Yes ■ No
LMP Date: ______________________
Is there anything else about your medical history that we should know? ______________________________________________________
____________________________________________________________________________________________________________________
Review of Systems:
Do you have the following symptoms? Please indicate Yes or No:
Fever
■ Yes
■ No
Abdominal Pain
■ Yes
■ No
Recent Wt Loss
■ Yes
■ No
Pain on Urination
■ Yes
■ No
Feeling Tired
■ Yes
■ No
Joint Pain
■ Yes
■ No
Eyesight Problems
■ Yes
■ No
Limb Pain
■ Yes
■ No
Loss of Hearing
■ Yes
■ No
Skin Lesions
■ Yes
■ No
Nasal Discharge
■ Yes
■ No
Dizziness
■ Yes
■ No
Sore Throat
■ Yes
■ No
Limb Weakness
■ Yes
■ No
Hoarseness
■ Yes
■ No
Difficulty Walking
■ Yes
■ No
Chest Pain
■ Yes
■ No
Muscle Weakness
■ Yes
■ No
Shortness of Breath ■ Yes
■ No
Easy Bruising
■ Yes
■ No
■ Yes
■ No
Seasonal Allergies
■ Yes
■ No
Cough
Patient Signature ___________________________________________________________________
Date ______________________
I certify that I have reviewed the above information with the patient.
Physician Signature _________________________________________________________________
Form 73087 (Rev. 05/08)
Date ______________________
JG 08.2865