Patient Health History
Name: _________________________ Date of birth: ________________ Age: __________
SS#: _____________________ Today’s Date: ________________ Sex: Male Height: ______
Marital Status: S M W D Separated
Female Weight: ______
Primary Care Physician: ______________________________ Phone number: ______________
Referring Physician: _________________________________ Phone number: ______________
Other physicians, include names,
specialties, and phone numbers:
____________________________________________________
Pharmacy Name: _________________________________ Pharmacy phone: _______________
Current problem or reason for visit: _________________________________________________
Do you feel the need to be linked to our social worker (counseling or financial issues)? Y/N ___
PAST MEDICAL HISTORY: Please check all the boxes that apply
Problem
Date of onset
Problem
Date of onset
Allergies
 ________
Hepatitis/Liver disease
 ________
High cholesterol
 ________
Anemia/Blood disorders  ________
Arthritis
 ________
High blood pressure
 ________
Asthma
 ________
Irregular heart beat
 ________
Blood clots
 ________
Kidney disease
 ________
Cancer
 ________
Pancreatitis
 ________
Cataracts
 ________
Sickle cell disease
 ________
Colitis
 ________
Sinusitis
 ________
Diabetes
 ________
Stroke
 ________
Emphysema
 ________
Thyroid
 ________
Tuberculosis
 ________
Heartburn/GERD/Reflux  ________
Glaucoma
 ________
Heart Disease
 ________
 ________
Ulcers
Other past medical history: __________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________
Any unusual childhood illnesses or infections? _______________________________________
OPERATIONS: Please list year, operation, and surgeon (if known)
1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
4. ____________________________________________________________________________
5. ____________________________________________________________________________
Have you:
Ever had a blood transfusion:
 Yes
 No If yes, when: _____________
Traveled outside the US in
the last three years?
 Yes
 No If yes, where: ____________
REPRODUCTIVE HISTORY:
Number of pregnancies: __________
Number of children: __________
Age at first pregnancy: ___________
Did you breast feed? __________
Age at first period: __________
Age at menopause: __________
Age of last period: __________
Hysterectomy:  Yes  No
Ovaries Intact? _____________
Hormone use:  Yes  No
Sex Drive  Yes  No
Birth Control Method: _____________________________________________________
Preventive Health Maintenance: please provide dates for each answer or write “none”
Female
Male
Last mammogram: ___________________
Last colonoscopy: ____________________
Last breast exam: ____________________
Last stool for occult blood: _____________
Last Pap smear: ______________________
Last prostate exam: ___________________
Last pelvic exam: ____________________
Last chest x-ray: ______________________
Last colonoscopy: ____________________
Last pneumonia vaccine: _______________
Last stool for occult blood: _____________
Last bone density scan: ________________
Last chest x-ray: ______________________
Last pneumonia vaccine: _______________
SOCIAL HISTORY:
Marital status: __________________________________________________________________
Number of children: ____________________ Age/Sex of children: _______________________
Spouse name: _________________________ Spouse occupation: ________________________
Patient occupation: _____________________ Highest level of education: __________________
Patient lives with:
Self 
Spouse 
Friend 
Other  ________________________________________
City of residence: ____________________
Child 
Sibling(s) 
Parent(s) 
Have you completed an advanced directive? Y / N
Have you completed a living will? Y / N
Smoking history
Cigarettes

How many years? ______________________________
Cigars

Number per day ______________________________
Pipes

If quit, when _______________________________

How many years? ___________________________
Wine

How much per day/week/month? ______________
Liquor

If quit, when_______________________________
Alcohol history
Beer
Recreational drug use 
Blood transfusions 
HIV testing 
ALLERGIES TO MEDICATIONS: please write “none” if none
Name of drug(s)/type of reaction:
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
MEDICATIONS/SUPPLEMENTS : please include over the counter drugs
Name of drug
Dose (mg or
mcg)
How many times daily
How long taking for
VACCINATIONS: Please provide date of last vaccination
Influenza: ________________
Shingles: ___________________
FAMILY HISTORY:
Relationship
Illness
Diagnosis Age
Deceased?
Mother:
_____________________________________
____________
YN
Father:
_____________________________________
____________
YN
Grandmother (P): __________________________________
____________
YN
Grandfather (P): __________________________________
____________
YN
Grandmother (M): __________________________________
____________
YN
Grandfather (M): __________________________________
____________
YN
Brothers:
___________________________________
____________
YN
Sisters:
___________________________________
____________
YN
Children:
___________________________________
____________
YN
Any other relatives with: Please check all the boxes that apply
Anemia 
Diabetes 
Blood clots 
Blood disorders 
Hypertension 
Stroke 
Heart disease 
Cancer  If so, what kind(s): _____________________________________________________
REVIEW OF SYSTEMS
Constitutional
Breast
Weight Loss
YN
Mass
YN
Poor energy level Y  N 
Pain
YN
Fever
Y  N  Nipple discharge Y  N 
Chills
Y  N  Change is size Y  N 
Night sweats
Y  N  Change in shape Y  N 
Eyes
Double vision
Vision loss
Flashing lights
Gastrointestinal
Nausea
YN
Vomiting
YN
Jaundice
YN
Abdominal pain Y  N 
Maroon or black stools Y  N 
Constipation
YN
Abdominal cramping Y  N 
Diarrhea
YN
Stomach pain Y  N 
Vomiting blood Y  N 
Difficulty swallowing Y  N 
YN
YN
YN
ENT/Mouth
Ringing in ears
YN
Oral ulcers
YN
Nasal drip
YN
Hearing loss
YN
Bleeding gums
YN
Mouth pain
YN
Nose bleeds
YN
Sore throat
YN
Difficulty swallowing Y  N 
Hoarseness
YN
Sinus pain
YN
Cardiovascular
Chest pain
YN
Leg swelling Y  N 
Palpitations
YN
Calf discomfort Y  N 
Fainting spells Y  N 
Arm swelling Y  N 
Skin
Rash
Nodules
Itchiness
Lesions
YN
YN
YN
YN
Neurological
Confusion
Seizures
Fainting spells
Tremors
Speech change
Headache
Hiccups
Abnormal gait
Weakness
Sensory change
YN
YN
YN
YN
YN
YN
YN
YN
YN
YN
Urinary
Psychiatric
Painful urination
YN
Depression Y  N 
Blood in urine
YN
Anxiety
YN
Impotence
Y  N  Difficulty Y  N
Loss of bladder control Y  N  concentrating
Increased frequency Y  N 
Gynecological
Vaginal discharge Y  N 
Pelvic pain
YN
Abnormal bleeding Y  N 
Vaginal dryness
YN
Respiratory
Musculoskeletal
Cough
YN
Muscle pain Y  N 
Wheezing
Y  N  Spine tenderness Y  N 
Shortness of breath Y  N  Swollen joints
YN
Endocrine
Excessive urine Y  N 
Excessive thirst
YN
Hot flashes
YN
Heat/cold intolerance Y  N 
Hematological
Nose bleeds
YN
Bleeding gums
YN
Purple spots on hands Y  N 
REVIEW OF SYSTEMS CONT.
Respiratory
Musculoskeletal
Coughing up blood
YN
Joint pain Y  N 
Pain with breathing Y  N 
Bone pain Y  N 
Hematological
Bruising Y  N 
Lymphatic
Enlarged lymph nodes Y  N 
Swelling in arms
YN
ADDITIONAL NOTES: Please use this space to complete any additional notes that were not
completed above. Please mark what section they correspond to.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Patient signature: ______________________________________________________________________
Patient printed name: ___________________________________________________________________
Date: ________________________________________________________________________________