MEDICAL HISTORY FORM: New Patient
NAME:_____________________________________________ DATE: _________________
DOB: ______________________________________________ AGE: __________________
NO ALLERGIES
ALLERGY
MEDICATIONS
Please List All
ALLERGIC REACTION
DOSE
(Mg, pill, etc.)
TIMES PER DAY
If you need more room to list medications, please write them on a blank sheet of paper with the required information
HEALTH MAINTENANCE SCREENING TEST HISTORY
Cholesterol
Date:
Facility/Provider:
Abnormal Result?
Colonoscopy/Sigmoid
Date:
Facility/Provider:
Abnormal Result?
Mammogram
Date:
Facility/Provider:
Abnormal Result?
Pap Smear
Date:
Facility/Provider:
Abnormal Result?
Bone Density
Date:
Facility/Provider:
Abnormal Result?
VACCINES HISTORY
Last Tetanus Booster or TdaP:
Last Pnuemovax:
Last Flu Vaccine:
Last Zoster:
PERSONAL MEDICAL HISTORY
DISEASE/CONDITION
CURRENT
PAST
COMMENTS
Alcoholism/Drug Abuse
Asthma
Cancer (type)
Depression/Anxiety/Bipolar/Suicidal
Diabetes (type)
Emphysema (COPD)
Heart Disease
High Blood Pressure (Hypertension)
High Cholesterol
Hypothyroidism/Thyroid Disease
Renal (kidney) Disease
Migraine Headaches
Stroke
Other:
Other:
Other:
SURGERIES
List what type of surgery (specify left/right), date of surgery, and location
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
WOMEN’S HEALTH HISTORY
Total Number of Pregnancies: ___________
Number of Live Births: _____________
Date of Last Menstrual Cycle: ____________
Age of First Menstruation: ___________
Age of Menopause: ___________________
Pregnancy Complications:
__________________________________________________________________
__________________________________________________________________
FAMILY MEDICAL HISTORY
Other
Other
Other
Migraines
Thyroid Disease
Stroke
Kidney Disease
High Blood Pressure
High Cholesterol
Heart Disease
Early Death
Diabetes
Depression/Anxiety
Bipolar/Suicidal
Emphysema (COPD)
Cancer (type)
Asthma
Alcohol/Drug Abuse
No Significant Family History is Known
Mother
Father
Sibling
Child
MGM
MGF
PGM
PGF
SOCIAL HISTORY
Occupation (or prior occupation): ___________________ retired/unemployed/LOA/disabled
Employer: ____________________
Years of Education or Highest Degree: ________
Marital Status (circle): Single / Partner / Married / Divorced / Widowed / Other
Who Lives at Home with You? _____________________________________________
OTHER HEALTH ISSUES
Tobacco Use
Smoke Cigarettes?
Never
No
Yes
(If you never smoked, please move to Alcohol Use)
Quit date: _________
How many years: ______
Alcohol Use
Do you drink alcohol?
Yes
#of drinks/week: ______
No
Beer Wine Liquor
How many packs did you smoke a day: ________
Drug Use
Do you use marijuana or recreational drugs? Yes No
Current smoker: Packs/day ____ #of Years ____
Have you ever used needles to inject drugs?
Yes No
Other Tobacco: Pipe Cigar
Have you ever taken someone else’s drugs?
Yes No
Snuff
Chew
Sexual Activity
Sexually involved currently?
Yes
Sexual partner(s) is/are/have been:
Male
Diet
How would you rate your diet? Good Fair Poor
No
Female
Birth control method: None Condom
Condom Pill/Ring/Patch/Inj/IUD Vasectomy
Exercise
Do you exercise regularly?
Yes
No
What kind of exercise? ____________________
____________________________________
____________________________________
How long (mins) _______ How often ________
Would you like advice on your diet?
Yes
No
Safety
Do you use a bike helmet?
Do you use seatbelts consistently?
Working smoke detector in home?
Yes
Yes
Yes
No
No
No
If you have guns at home, are they locked up?
Yes
No
Is violence at home a concern for you?
No
Yes
Have you completed an Advance Directive for Health
Care (ADHC), Living Will, or Physical Orders for Life
Sustaining Therapy (POLST)?
Yes
No
OTHER PROVIDERS/SPECIALISTS
SPECIALIST
Cardiology
GI
GYN
Neurology
Pulmonary
Other:
Other:
NAME
LAST VISIT
REVIEW OF SYSTEMS
SKIN
Rash
Sores
Changes with a Mole
Itching/Dryness
Hair and Nail Changes
EARS
Loss/decrease of hearing
Drainage from ears
Ringing
Earache
EYES
Blurry Vision
Drainage from eyes
Pain
Vision loss/changes
Flashing lights/Dots
HEART
Heart Murmur/Palpitations
Chest pains/discomfort/
Tightness
Swelling
Leg pain when walking
SKELETON
Pain in joints
Stiffness
GASTRO
Change in appetite
Problems swallowing
Abdominal
Wheezing
Nausea/Diarrhea
Change in bowel habits
Rectal Bleeding
Constipation
URINARY
Frequency
Urgency
Burning or Pain
Blood in Urine
Incontinence
Change in Urinary strength
NEUROLOGIC
Dizziness
Fainting
Seizures
Weakness
Numbness
Tingling
Tremor
ENDOCRINE
Heat/Cold Intolerance
Sweating
Thirst
Change in appetite
HEAD
Headaches/Migraines
Neck Pain
Head Injury
PSYCHIATRIC
Nervousness
Stress
Depression
Memory Loss
BREAST
Lump(s)
Pain
Discharge
Tenderness
Color Changes
VAGINAL
Discharge
Hot Flashes
Change in Periods
Itching or Dryness
Pain with Sex
Loss of Sex Drive
Lesions/Sores
PROSTATE
Lump(s)
Pain/Pain with Sex
Lesions/Sores
Loss of Sex Drive
Hernia
LUNGS
Cough
Difficulty/Painful
breathing
Coughing up blood
Wheezing
Swollen joints
Back Pain