PATIENT PERSONAL HISTORY Note to patient: The examining Medical Provider requests that you complete this brief history. This form and information is CONFIDENTIAL and will become a part of your medical record. PERSONAL DATA Patient First Name:_________________________ Last Name:_____________________ Date:__________________ DOB:_______________ Sex:__________ Status:___________ Occupation:_________________________________ Address:_________________________________________________ Phone:________________________________ PRESENTING COMPLAIN __________________________________________________________________________________________________ __________________________________________________________________________________________________ MEDICATIONS: (include over the counter medications) _________________________________________________________________________________________________ ALLERGIES: NO YES If yes, Please list:______________________________________________________________ HOSPITALIZATION/ SURGERIES: Date: _________________ Reason:__________________________________________________________________ Date: _________________ Reason:__________________________________________________________________ Date: _________________ Reason:__________________________________________________________________ PERSONAL HISTORY/REVIEW OF SYSTEMS: Have you experienced any of following? Circle and explain. Hepatitis/Liver Disease Diabetes High Blood Pressure Blood Disorder/ Bleeding Aids or HIV positive Cancer Heart Disease/ Murmur Anemia Psychological Problem Elevated Cholesterol Kidney Disease STDS Skin Condition Epilepsy Asthma PREGNANCY Arthritis/ Back Pain/ Injury Heart Burn Tuberculosis (TB) NURSING Anxiety/ Depression Gastrointestinal Disease Pulmonary Disease Other Explain all circled items: __________________________________________________________________________________________________ __________________________________________________________________________________________________ FAMILY HISTORY: Does a family member suffer from any of the conditions above? Explain below. __________________________________________________________________________________________________ SOCIAL HISTORY: Do you use/used any of the following: Smoke Tobaco Pan Other Beetle nut Alcohol The above answers are true and accurate. I realize that any untrue answers may affect my evaluation and treatment, the Examiner’s recommendations, treatment plan, and validity of this examination. PATIENT SIGNATURE: ______________________________________ Date:____________ ________________________DO NOT WRITE BELOW THIS LINE________________________ Medical Provider Comments: _________________________________________________________________ __________________________________________________________________________________________ Medical Provider : _________________________________ Medical Provider Signature: _________________________ Date:____________ TREATMENT RECORD VISIT DATE TREATMENT ADVISED TREATMENT DONE PAYMENT SIGN