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.
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: ____________
Medical Provider Comments: ____________________________________________________________
_____________________________________________________________________________________
Medical Provider : _________________________________
Medical Provider Signature: _________________________
Date:____________
TREATMENT RECORD
VISIT
DATE
TREATMENT ADVISED
TREATMENT DONE
PAYMENT
SIGN