Patient Health History
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Patient Name: __________________________________________ DOB: _____/_____/_____ (mm/dd/yy) Present Complaint _________________________________________________________________________ __________________________________________________________________________________________ __________________________ Duration of complaints/problems: _________________________________ PAST MEDICAL HISTORY: NEGATIVE/UNREMARKABLE OR BOX THAT APPLIES TO YOU Medical Anemia Anxiety Asthma Atrial Fibrillation Autoimmune Disorder BPH Cancer- Breast Cancer – Lung Medical GERD/Reflux Glaucoma Gout Heart Disease Hepatitis type:_______ Neurologic Aneurysm CVA/Stroke Brain Tumor Hydrocephalus Migraines HIV High cholesterol/lipids Hypertension/High BP Cancer- Renal Cancer- Colon Cancer- Prostate Cataracts COPD Irritable Bowel Syndrome Heart Attack Nasal Allergies Osteoarthritis Osteoporosis Renal Disease Rheumatoid Arthritis Sleep Apnea Thyroid Disease: high/low Vision loss Multiple Sclerosis Parkinson’s Disease Peripheral Neuropathy Pituitary tumor Seizure Disorder Spinal Cord Injury TIA Traumatic Brain Injury Trigeminal Neuralgia Depression Diabetes - Type 1 Diabetes - Type 2 Fibromyalgia PAST SURGICAL HISTORY: NO PREVIOUS SURGERIES Year of surgery: Type of surgery: COTINUED TO PAGE 2 Pertinent to surgery Anticoagulation Therapy Bleeding Disorder Chronic Pain Clotting Disorder DVT Hemophilia Narcotic use > 6 months Problems w/ Anesthesia Pulmonary Embolism Other: Please list any other diagnosis not on this list: ALLERGIES: No known drug allergies List medication, food, and environmental allergies Allergic to: Reaction: If you require more room, please write allergies on separate piece of paper. CURRENT MEDICATIONS: NONE Medication name & dose Example: Atenolol 50mg How often Example: one tab daily, one tab twice daily, two tabs at bedtime If you require more room, please list your medications, doses & frequency on a separate sheet of paper and attach. CONTINUED TO PAGE 3 FAMILY HISTORY: UNKNOWN ADOPTED NO FAMILY HISTORY OF CHRONIC DISEASE the diagnosis that apply for each of your immediate family members: Mother Father Sister Brother Alcoholism Anemia Angina Arthritis Asthma Birth Defects Blood Clots Bowel Disease Breast Cancer Cervical Cancer Colon Cancer Depression Diabetes Growth/ Development Problems Headaches Heart Disease Hypertension/ Alcoholism Anemia Angina Arthritis Asthma Birth Defects Blood Clots Bowel Disease Breast Cancer Cervical Cancer Colon Cancer Depression Diabetes Growth/ Development Problems Headaches Heart Disease Hypertension/ Alcoholism Anemia Angina Arthritis Asthma Birth Defects Blood Clots Bowel Disease Breast Cancer Cervical Cancer Colon Cancer Depression Diabetes Growth/ Development Problems Headaches Heart Disease Hypertension/ High BP High BP High Cholesterol Kidney Disease Liver Disease Lung Cancer Melanoma/ Skin Cancer Osteoporosis Other Cancer Ovarian Cancer Psychiatric Care Respiratory disease Seizures Severe allergies Stroke Thyroid Disease Uterine Cancer High Cholesterol Kidney Disease Liver Disease Lung Cancer Melanoma/ Skin Cancer Osteoporosis Other Cancer Ovarian Cancer Psychiatric Care Respiratory disease Seizures Severe allergies Stroke Thyroid Disease Uterine Cancer CONTINUED TO PAGE 4 Alcoholism Anemia Angina Arthritis Asthma Birth Defects Blood Clots Bowel Disease Breast Cancer Cervical Cancer Colon Cancer Depression Diabetes Growth/ Development Problems Headaches Heart Disease Hypertension/ Maternal Grandmother Alcoholism Anemia Angina Arthritis Asthma Birth Defects Blood Clots Bowel Disease Breast Cancer Cervical Cancer Colon Cancer Depression Diabetes Growth/ Development Problems Headaches Heart Disease Hypertension/ Maternal Grandfather Alcoholism Anemia Angina Arthritis Asthma Birth Defects Blood Clots Bowel Disease Breast Cancer Cervical Cancer Colon Cancer Depression Diabetes Growth/ Development Problems Headaches Heart Disease Hypertension/ Paternal Grandmother Alcoholism Anemia Angina Arthritis Asthma Birth Defects Blood Clots Bowel Disease Breast Cancer Cervical Cancer Colon Cancer Depression Diabetes Growth/ Development Problems Headaches Heart Disease Hypertension/ Paternal Grandfather Alcoholism Anemia Angina Arthritis Asthma Birth Defects Blood Clots Bowel Disease Breast Cancer Cervical Cancer Colon Cancer Depression Diabetes Growth/ Development Problems Headaches Heart Disease Hypertension/ High BP High BP High BP High BP High BP High BP High Cholesterol Kidney Disease Liver Disease Lung Cancer Melanoma/ Skin Cancer Osteoporosis Other Cancer Ovarian Cancer Psychiatric Care Respiratory disease Seizures Severe allergies Stroke Thyroid Disease Uterine Cancer High Cholesterol Kidney Disease Liver Disease Lung Cancer Melanoma/ Skin Cancer Osteoporosis Other Cancer Ovarian Cancer Psychiatric Care Respiratory disease Seizures Severe allergies Stroke Thyroid Disease Uterine Cancer High Cholesterol Kidney Disease Liver Disease Lung Cancer Melanoma/ Skin Cancer Osteoporosis Other Cancer Ovarian Cancer Psychiatric Care Respiratory disease Seizures Severe allergies Stroke Thyroid Disease Uterine Cancer High Cholesterol Kidney Disease Liver Disease Lung Cancer Melanoma/ Skin Cancer Osteoporosis Other Cancer Ovarian Cancer Psychiatric Care Respiratory disease Seizures Severe allergies Stroke Thyroid Disease Uterine Cancer High Cholesterol Kidney Disease Liver Disease Lung Cancer Melanoma/ Skin Cancer Osteoporosis Other Cancer Ovarian Cancer Psychiatric Care Respiratory disease Seizures Severe allergies Stroke Thyroid Disease Uterine Cancer High Cholesterol Kidney Disease Liver Disease Lung Cancer Melanoma/ Skin Cancer Osteoporosis Other Cancer Ovarian Cancer Psychiatric Care Respiratory disease Seizures Severe allergies Stroke Thyroid Disease Uterine Cancer SOCIAL HISTORY/ADDITIONAL INFORMATION: Tobacco use: Current every day smoker Current some day smoker Former Smoker Never Smoker Passive Smoke Exposure Yes No Alcohol Use No Yes, Type:_________ How many drinks per day ______ Recreational Drug Use: Employment Status: No Yes, Type: __________ How often _________ Employed Unemployed Retired Disabled Self-employed What is or was your occupation: ___________________________ Marital Status: Married Partner Single Divorced Widowed Handedness: Height _________ Weight: ________ lbs. Right-hand dominant Left-hand dominant Ambidextrous This information is true and complete to the best of my knowledge. _________________________________________________ Signature _________________________ Date
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