PATIENT HISTORY FORM
Today’s Date: Click here to enter a date.
DEMOGRAPHICS
Name:
Date of Birth:
Marital Status: Single ☐
Married ☐
Widowed ☐
Separated ☐
Divorced ☐
Employer/Occupation:
Primary Care Physician:
MEDICATIONS
Allergies to Medications:
Current Medications: (List all; including ones not prescribed, such as alternative agents or herbal supplements)
Drug
Strength
How Often You Take Per Day
ILLNESS / HOSPITALIZATION
Childhood Illnesses: Chicken Pox ☐
Measles ☐
Mumps ☐
Previous Medical Illness / Hospitalizations (other than surgery):
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Rubella ☐
Scarlet Fever ☐
PATIENT HISTORY FORM
Name:
Date of Birth:
SURGERY
If yes, please check and give the approximate date of surgery in the corresponding blank.
☐ Gallbladder
☐ Hernia Repair
☐ Appendectomy
☐ Heart Angioplasty
☐ Tonsillectomy
☐ Heart Bypass
☐ Hysterectomy
☐ Pacemaker
☐ Mastectomy
☐ Other
☐ Tracheotomy
☐ Vasectomy
☐ Hip Replacement
☐ Knee Replacement
FAMILY MEDICAL HISTORY
Check the box next to the condition that your family member has; then specify their relation to you
after the disease; using the abbreviations as follows (you can use more than one for each - please separate each
additional entry with a comma):
(M)-Mother
(S)-Sister
(PGM) Paternal Grandmother
(MU) Maternal Uncle
☐ Alcoholism
☐ Anemia
☐ Asthma
☐ Arthritis
☐ Breast Cancer
☐ Colon Polyps
(F)-Father
(MGM)-Maternal Grandmother
(PGF) Paternal Grandfather
(PA) Paternal Aunt
☐ Diabetes
☐ Glaucoma
☐ Heart Disease
☐ High Blood Pressure
☐ Kidney Disease
☐ Migraines
(B)-Brother
(MGF) Maternal Grandfather
(MA) Maternal Aunt
(PU) Paternal Uncle
☐ Osteoporosis
☐ Prostate Cancer
☐ Stroke/TIA
☐ Thyroid Disease
☐ Cancer
☐ Other
Enter "Other" Here
Living
Mother
Yes☐ No☐
Father
Yes ☐ No☐
Age or Age at Death
Sibling (1) Yes ☐ No☐
Sibling (2) Yes ☐ No☐
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Present Health or Cause of Death
PATIENT HISTORY FORM
Sibling (3) Yes ☐ No☐
Name:
Date of Birth:
MEDICAL HISTORY
Please check any of the listed items that apply to your medical history (past or present).
☐ Urinary Incontinence
☐ Blurred Vision
☐ Glaucoma
☐ Headaches
☐ Migraine Headaches
☐ Lumps or Swelling in Neck
☐ Constant Ringing in Ears
☐ Hearing Problems
☐ Frequent Earaches
☐ Frequent Nosebleeds
☐ Sinus Infections
☐ Allergies / Hay Fever
Lungs ☐ Asthma
☐ Have Coughed up Blood
☐ Increasing Shortness of Breath
☐ Pneumonia
☐ Emphysema
☐ History of Tuberculosis
☐ Chronic Cough
Heart ☐ Irregular Heartbeats / Palpitations
☐ Chest Pain or Tightness
☐ Heart Murmur / Valve Problems
☐ History of Enlarged Heart
☐ Swelling of Feet and Ankles
☐ History of Rheumatic Fever
☐ High Blood Pressure
☐ Previous Heart Attack
Neuro. ☐ Seizures
☐ Loss of Consciousness
☐ Double Vision
☐ Memory Loss
☐ Numbness of Hands or Feet
☐ Stroke
Kidney ☐ Recurrent Urinary Tract Infections
☐ Urination at Night More Than Once
☐ Blood in Urine
☐ Burning on Urination
☐ Kidney Stones
☐ Difficulty Starting Stream
☐ Problems with Sexual Function
Head
Abdomen ☐ Heartburn
☐ Difficulty or Pain Swallowing
☐ Have Vomited Blood
☐ Rectal Pain/Bleeding (Black Blood)
☐ Recent Changes in Bowel Habits
☐ Diverticulitis or Diverticulosis
☐ Colon Polyps
☐ Colonoscopy Click here to enter a date.
☐ Hepatitis / Yellow Jaundice
☐ Liver Disease
☐ Nausea
☐ Constipation
☐ Diarrhea
☐ Abdominal Pain
☐ Hemorrhoids
☐ Hernia
☐ Loss of Appetite
Joints
☐ Back Trouble
☐ Swollen Joints
☐ Frequent Painful Feet
☐ Frequent Shoulder Pain
☐ Aching of Muscles
☐ Aching of Joints
☐ Gout
☐ Arthritis
☐ Osteoporosis
General ☐ Diabetes (Diagnosed: Click here to enter a date.)
☐ Weight Loss or Weight Gain
☐ Fevers / Chills
☐ Night Sweats
☐ Sleeping Difficulty
☐ Sleep Apnea Choose an item.
☐ Thyroid Problems
☐ Increased Fatigue / Malaise
☐ Leg Cramps While Walking
☐ Depression
☐ Anxiety
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PATIENT HISTORY FORM
☐ Anemia
☐ History of High Cholesterol
☐ Other
Name:
Date of Birth:
MEDICAL HISTORY CONTINUED
Males Only
☐ Weak Urine Stream
☐ Painful or Sore Genitals
☐ Prostate Issues
☐ Hard to Empty Bladder Completely
☐ Perform Self Testicular Exams Monthly
☐ Erectile Dysfunction
Females Only
☐ Last Menstrual Period (Date: Click here to enter a date.)
☐ Vaginal Discharge or Problems
☐ Painful or Sore Genitals
☐ Lumps or Pain in Breast
☐ Last Mammogram (Date: Click here to enter a date.)
☐ Last Pap-Smear (Date: Click here to enter a date.)
☐ Perform Self Breast Exams Monthly
ADDITIONAL NOTES / COMMENTS:
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PATIENT HISTORY FORM
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