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? If yes, start date/quit date?_________________________________ Do you drink alcohol? 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 ________________ Kidney Problems Asthma ________________ Liver Problems/Hepatitis Blood Disorder ________________ Lung Problems Cancer ________________ Neuro: Seizures, Epilepsy Diabetes ________________ Psychiatric Gastrointestinal ________________ STD Genitourinary/Prostate ________________ Skin Disorders Heart Problems ________________ Thyroid High Blood Pressure ________________ Other High Cholesterol ________________ Women Yes No Last Menses: Pregnant ________________ Hysterectomy Self Family 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)