PATIENT REGISTRATION & MEDICAL HISTORY – Part 1
Patient’s Name________________________________________________
Date ____________________
Address __________________________________________________ City/State _____________________ Zip Code ___________
I currently take the following medications. Please include all prescriptions, non-prescription and over the counter (OTC)
medicines, including inhalers, vitamins, herbs and supplements.
NONE________
Medicine - Name How much?
Strength or dose
Why am I taking it? How often do I take Who ordered this medicine?
this medicine?
I am Allergic to the following medicines:
I am not allergic to any medications_________
Mark Below if
Allergic To This
Type of Reaction
Anaphylaxis Rash Itching Nausea Other / Describe
Penicillin
Codeine
Sulfa
Erythromycin
Shellfish/Iodine/Dye
Latex
Tape
Other: Please list
Have you had a recent flu vaccine? _____ No ____ Yes – if yes, what month? __________________
If you are over 65 years old – have you had pneumonia vaccine? ______ No _____ Yes – if yes, what year? _______
Medical History- Please indicate if you have had any of the following problems (check all boxes that apply):
I do not have any of the problems listed below_________
Disease/Problem
I have this problem
AIDS/HIV Positive
Angina
Asthma
Bleeding Disorder
Blood Clot
Cancer
Depression/Anxiety
Diabetes
Heart Attack
Gout
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
Irregular Heart Rate
Kidney Stones
Kidney Disease
Liver Disease
Lung Disease
Seizures
Stroke
Substance Abuse
Tuberculosis
Other : _________________________
Social History
Smoking History: I have never smoked_____
I smoke a pipe or cigars____
I have quit ____
I smoke an e-cigarette____
I drink alcohol: Never_____
rarely _____
7 or more drinks per day____
Yes I smoke_____
# of packs of cigs per day____
I chew tobacco_____
1-2 drinks per day____
3-4 drinks per day___
5-6 drinks per day___
Past Medical History
I have had the following surgical procedures performed:
NONE__________
Year________ Operation_____________________________________ Which side? Right___ Left___ Does not apply___
Year________ Operation_____________________________________ Which side? Right___ Left___ Does not apply___
Year________ Operation_____________________________________ Which side? Right___ Left___ Does not apply___
Year________ Operation_____________________________________ Which side? Right___ Left___ Does not apply___
Family History: Please indicate if anyone in your family has had any of the following (check all boxes that apply):
No one in my family has any of the problems listed below_________
Disease/Problem
Father
Mother
Brother
Sister
Other Relative
Indicate relationship
AIDS/HIV Positive
Angina
Asthma
Bleeding Disorder
Blood Clot
Cancer
Depression/Anxiety
Diabetes
Heart Attack
Gout
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
Irregular Heart Rate
Kidney Stones
Kidney Disease
Liver Disease
Lung Disease
Seizures
Stroke
Substance Abuse
Tuberculosis
Other :
_________________________
Review of Systems: Have you had any of the following during the past three months?
Constitutional/ Paseo
General Good Health Lately No Yes
Musculoskeletal
Joint Pain
No Yes
Recent Weight Change
No Yes
Joint stiffness or swelling
No Yes
Cardiovascular
Irregular heart beat
No Yes
Weakness of muscles or joints No Yes
Chest Pains
No Yes
Muscle pain or cramps
No Yes
Psychiatric / Psiquiátrico
Memory Loss or confusion
No Yes
Back pain
No Yes
Nervousness
No Yes
Cold Extremities
No Yes
Depression
No Yes
Difficulty Walking
No Yes
No Yes
Respiratory
Asthma or wheezing
No Yes
Shortness of breath
No Yes
Sleep Problems