3762 Durham Road Suite A
Roxboro, North Carolina 27573
336.330.0400
info@medaccess-uc.com
700 US 1 Highway Suite 100
Youngsville, North Carolina 27596
919.562.2340
www.medaccess-uc.com
PATIENT MEDICAL HISTORY FORM
(The following information is very important to your health and will better allow our practice to serve you. Please take your time to fill out this
form completely.)
Name: __________________________________________________________ DOB: ________________________ Age: _______
Height: _____________________________ Weight: ______________________________ Gender:  Male  Female
Reason for today’s visit: ____________________________________________________________________________________
Primary Care Provider: ______________________________________
Office Use Only
Resp: ___ _ _ ______
ALLERGIES
Temp: __________
O2 Sat: ___ ____ ___
Are you allergic to any medicines (including any tape, iodine or latex)
Pulse: ______ ____
Weight: __________
 No
 Yes (If yes, please complete the allergy information below)
Medications:
BP: ______/__ ____
Height: _____ __ ___
Type of Reaction you experience:
PAST SURGICAL HISTORY
Type of Operation
Date of Operation
CURRENT MEDICATIONS
Medication
Dose
Frequency
Medication
Dose
Frequency
SOCIAL HISTORY
Yes
No
Do you smoke?


If yes, how much per day and how many years? ________________
Have you ever smoked?

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If yes, start date/quit date?_________________________________
Do you drink alcohol?

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If yes, how much and how often?____________________________
Do you do street/unprescribed drugs?


If yes, please specify. _____________________________________
Date of your last Tetanus Shot?___________________________
MEDICAL HISTORY (Please check only if a history exists for yourself or a family member)
Self Family
Relationship to you
Arthritis

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________________
Kidney Problems
Asthma
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________________
Liver Problems/Hepatitis
Blood Disorder
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________________
Lung Problems
Cancer
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________________
Neuro: Seizures, Epilepsy
Diabetes

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________________
Psychiatric
Gastrointestinal
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________________
STD
Genitourinary/Prostate 
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________________
Skin Disorders
Heart Problems


________________
Thyroid
High Blood Pressure 

________________
Other
High Cholesterol


________________
Women
Yes
No
Last Menses:
Pregnant


________________
Hysterectomy


Self Family
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Relationship to you
________________
________________
________________
________________
________________
________________
________________
________________
________________
Patient/Guardian Signature___________________________________________ Today’s Date___________________________
(The information provided on this form is true and correct to the best of my belief)