Clinic Use Only:
Patient Health History
PRN: __________________
MRN: __________________
Date:
Age:
Name:
☐M ☐F
Sex:
Birth Date:
Last
First
SSN:
M.I.
PERSONAL HEALTH HISTORY
Immunizations (please check immunizations and list date received):
☐ Tetanus
☐ Hepatitis B
☐ Pneumonia
☐ Chicken Pox
☐ Hepatitis A
☐ Influenza (Flu)
☐ MMR
☐ Other: _____________
Last Physical Examination:
Date:
By:
Where:
By:
Where:
Last Dental Examination:
Date:
Emergency Room visits (please list all Emergency Room visits within the past 2 years):
Date/ Reason/ Hospital:
Hospitalizations (please list all hospitalizations):
Date/ Event/ Hospital:
Surgeries (please check surgeries and list date)
☐ Appendix
☐ Gall Bladder
☐ Heart Bypass
☐ Hysterectomy
☐ Mastectomy/ Breast Biopsies
☐ Tonsils
☐ Other:_________________________________
☐ Other:_________________________________
Medications (please list all medications you are currently taking - including prescription & over-the-counter medications, vitamins, supplements, & herbals) :
Medication/ Dosage/ Frequency:
Reason for taking:
Allergies (please list all allergies – medication, food, latex, and/ or environmental):
Allergic to:
Reaction you had:
Past Medical History - Do you currently have or have you had:
☐ AIDS
☐ Alcoholism
☐ Anemia
☐ Anorexia
☐ Appendicitis
☐ Arthritis
☐ Asthma
☐ Bleeding Disorders
☐ Breast Lump
Form FP005 (Rev 1)
☐ Bronchitis
☐ Bulimia
☐ Cancer
☐ Cataracts
☐ Chemical Dependency
☐ Chicken Pox
☐ Diabetes
☐ Emphysema
☐ Epilepsy
☐ Glaucoma
☐ Goiter
☐ Gonorrhea
☐ Gout
☐ Heart Disease
☐ Hepatitis
☐ Hernia
☐ Herpes
☐ High Cholesterol
☐ HIV Positive
☐ Kidney Disease
☐ Liver Disease
☐ Measles
☐ Migraine Headaches
☐ Miscarriage
☐ Mononucleosis
☐ Multiple Sclerosis
☐ Mumps
☐ Pacemaker
☐ Pneumonia
☐ Polio
☐ Prostrate Problem
☐ Psychiatric Care
☐ Rheumatic Fever
☐ Scarlet Fever
☐ Stroke
☐ Suicide Attempt
☐ Thyroid Problems
☐ Tonsillitis
☐ Tuberculosis
☐ Typhoid Fever
☐ Ulcers
☐ Vaginal Infections
☐ Venereal Disease
☐ Other: __________
☐ Other: __________
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Clinic Use Only:
Patient Health History
PRN: __________________
MRN: __________________
Current Symptoms – Are you currently experiencing or have you experienced in the past year:
General:
Gastrointestinal:
Eyes, Ears, Nose, & Throat:
☐ Chills
☐ Depression
☐ Dizziness
☐ Fainting
☐ Fever
☐ Forgetfulness
☐ Headache
☐ Nervousness
☐ Numbness
☐ Sleep Loss
☐ Sweats
☐ Weight Gain/Loss
☐ Appetite Poor
☐ Bloating
☐ Bowel Changes
☐ Constipation
☐ Diarrhea
☐ Excessive Hunger
☐ Excessive Thirst
☐ Gas
Muscles, Joints, & Bones
☐ Hemorrhoids
☐ Indigestion
☐ Nausea
☐ Rectal Bleeding
☐ Stomach Pain
☐ Vomiting
☐ Vomiting Blood
Cardiovascular:
(Pain, Weakness, or Numbness in):
☐ Arms
☐ Hips
☐ Back
☐ Legs
☐ Feet
☐ Neck
☐ Hands
☐ Shoulders
☐ Chest Pain
☐ High Blood Pressure
☐ Irregular Heartbeat
☐ Low Blood Pressure
☐ Hoarseness
☐ Hearing Loss
☐ Nosebleeds
☐ Persistent Cough
☐ Ringing in Ears
☐ Sinus Problems
☐ Vision – Flashes
☐ Vision - Halos
Skin:
☐ Poor Circulation
☐ Rapid Heart Beat
☐ Swelling of Ankles
☐ Varicose Veins
Pulmonary (Lungs):
☐ Cough
☐ Coughing Up Blood
☐ Bleeding Gums
☐ Blurred Vision
☐ Crossed Eyes
☐ Difficulty Swallowing
☐ Double Vision
☐ Earache
☐ Ear Discharge
☐ Hay Fever
☐ Bruise Easily
☐ Hives
☐ Itching
☐ Change in Moles
☐ Rash
☐ Scars
☐ Sore That Won’t Heal
Genitourinary:
☐ Pain with Cough
☐ Productive Cough
☐ Shortness of Breath
☐ Wheezing
☐ Blood in Urine
☐ Frequent Urination
☐ Lack of Bladder Control
☐ Painful Urination
☐ Lump in Testicles
☐ Penis Discharge
☐ Sore on Penis
☐ Erection Difficulties
Men Only:
☐ Breast Lump
Women Only:
☐ Abnormal Pap Smear
☐ Breast Lump
☐ Nipple Discharge
☐ Extreme Menstrual Pain
☐ Bleeding Between Periods
☐ Hot Flashes
☐ Painful Intercourse
☐ Vaginal Discharge
Menstrual Flow:
☐ Regular
☐ Irregular
Number of :
Pregnancies: __________
Date of Last:
Pap Test: __________
☐Pain/Cramps
# of days of flow: __________
Births: __________
☐ Normal
☐ Abnormal
Length of cycle: ___________ Date of Last: _____________
Miscarriages: __________
Mammogram: __________
Abortions: __________
☐ Normal
☐ Abnormal
FAMILY HEALTH HISTORY
Please indicate if any blood relative has history of illness and which relative (M = mother, F = father, S = sibling, G = grandparent)
☐ Alcoholism __________
☐ Anemia __________
☐ Arthritis __________
☐ Asthma/Allergy __________
☐ Bleeding Disorder __________
☐ Cancer __________
☐ Depression __________
☐ Diabetes __________
☐ Epilepsy __________
☐ Glaucoma __________
☐ Hay Fever __________
☐ Heart Disease __________
☐ Hepatitis __________
☐ High Blood Pressure __________
☐ Lipid Disorder __________
☐ Mental Illness __________
☐ Migraines __________
☐ Osteoporosis __________
☐ Stroke __________
☐ Thyroid Disease __________
HEALTH HABITS & PERSONAL SAFETY
Do you drink alcohol?
☐Yes ☐No
If Yes, What kind?
How many drinks per day?
Per week?
☐Yes ☐No
Tobacco: Have you ever used tobacco?
What kind?
How much?
How long? When did you quit?
Do you use recreational or street drugs of any kind?
☐Yes ☐No
Drugs:
What kind? How much?
☐Coffee, # per day:
☐Tea, # per day:
☐Cola, # per day:
Caffeine: ☐None
☐None
☐Mild
(climb
stairs,
walk)
☐Occasional
Vigorous
(30
minutes,
<
4x/
week)
☐Regular Vigorous (30 minutes, ≥ 4x/ week)
Exercise:
Alcohol:
Diet:
Sex:
Are you dieting? ☐Yes ☐No with medical supervision?
How many meals to you eat in an average day?
Are you sexually active?
☐Yes ☐No
Personal Safety:
Patient Signature:
Form FP005 (Rev 1)
Do you live alone?
☐Yes ☐No
Do you have vision or hearing loss?
☐Yes ☐No
Do you have frequent falls?
☐Yes ☐No
☐Yes ☐No
Date:
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