The Greenville MD, PA
2317 Executive Park Circle, Suite A
Greenville, NC 27834
Personal History Form
Date: _______________
Last Name: ________________________________First Name: _______________________ MI: ______
Date of Birth: ____________________________ Gender: (please circle one) Male Female
Previous Physician’s name: _____________________Date of last exam: ________________________
CHIEF COMPLAINT
Reason for visit today:_________________________________________________________________
Past Medical History
Which of the following conditions are you currently being treated or have been treated for in the past (please
check)
□Heart
disease/Murmur/Angina
□Shortness of breath
□Eye disorder/Glaucoma
□Diabetes
□High cholesterol
□Asthma
□Seizures
□Kidney/Bladder problems
□High blood pressure
□Lung problems/cough
□Cancer
□Stroke
□Anemia or blood problems
□Liver problems/Hepatitis
□Depression/Anxiety
□Low blood pressure
□Ulcers/colitis
□Sinus problems
□Swollen ankles
□Headaches/Migraines
□Ear problems
□Arthritis
□Psychiatric care
□Heartburn (reflux)
□Thyroid problems
□Seasonal allergies
□Neurological problems
Please describe/list any current or past medical treatment not listed above
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list your past surgeries _____________________________________________________________________________________
The Greenville MD, PA
2317 Executive Park Circle, Suite A
Greenville, NC 27834
Allergies
Are you allergic to penicillin or any other drugs? □Yes □No
Please list: _______________________________ Type of reaction: ______________________________
_________________________________ Type of reaction: ______________________________
Medications
Please list all medications you currently take and the doses, include non-prescription medications.
Medication
Dose /Strength/How Often
__________________________________
_______________________________
__________________________________
_______________________________
__________________________________
_______________________________
__________________________________
______________________________
Social and Preventive History
Do you currently smoke or chew tobacco? □Yes □NoIf no, have you in the past? □Yes □No
How many packs per day? _______________________How many years? ______________
Do you drink alcohol, beer, or wine? □Yes □No If no, have you in the past? □Yes □No
How many drinks per week? ______________________
Do you currently drink coffee, soft drinks and/or tea? □Yes □No If yes, how many cups, glasses or cans per
day? ________________________
Do you exercise daily/weekly? □Yes □NoIf yes, describe ________________________________
Do you use seatbelts while driving? □Yes □No
The Greenville MD, PA
2317 Executive Park Circle, Suite A
Greenville, NC 27834
Family History
Has any member of your family (including parents, siblings and children) had any of the following Illnesses:
Illness
Which family member/Age if deceased?
Anemia/Blood disease
_______________ ____
High blood pressure
Cancer
_______________ ____
HIV disease/AIDS
_____
Diabetes
_____
_______________
_______________ _____
______________
Mental Illness/Depression______________ _____
Glaucoma
_______________ _____
Stroke
______________ _____
Heart disease
_______________ _____
Other serious Illness _________________________
Females: Gynecological History
How many times have you been pregnant? ______________ Date of last Pap Smear_______________________
Have you had an abnormal Pap Smear? □Yes □No Diagnosis: _______________ Follow up: ______________
Have you had a sexually transmitted disease? □Yes □No Diagnosis: ______________________________________
Date of last mammogram: ________________________ Mammogram results: ____________________________
Have you ever had a breast biopsy? □Yes □No Biopsy results: ___________________________________
Males: History
Loss of sexual activity/desire?__________________
Discharge from penis?_____________
Treatment of genitals (private parts)?____________
Hernia (rupture)?_________________
Prostate trouble?_______________
By signing below, I hereby certify that to the best of my knowledge all the information I have
furnished on this form is complete, true and accurate.
Patient/Legal Guardian Signature ____________________________________________
Date _____________________________