Medical and Health History Form
Patient Name:_______________________________
Age:_______ Birthdate:
Please answer all questions as accurately as possible. If you do not understand the question, please ask for
assistance.
Reason for today’s visit: __________________________ Primary care doctor: ________________________
Do you smoke nicotine? Yes No
Do you use Marijuana? Yes No
Height __________Weight______________ Drug Allergies:
___________________________
List previous surgeries (Cosmetic and medical) or major illnesses and dates:
List any medications you are taking, including non-prescription drugs, vitamins, and herbals:
_______________________________________________________________________________________
Preferred Pharmacy: ____________________________________ Phone:_______________________________
Family History:
Has any blood relative ever had the following: (please circle F-father; M-mother; S-sister; B-brother)
□Breast Cancer F M S B
□ Melanoma F M S B
Father: Alive
Deceased
□High Blood Pressure F M S B □ Heart Disease F M S B
Mother: Alive
Deceased
□Kidney Disease F M S B
□ Depression F M S B
Brother: Alive
Deceased
□Stroke F M S B…A D
□Diabetes F M S B
Sister: Alive
Deceased
Past Medical History:
Have you ever had the following:
□Heart Disease
□Arthritis
□Cancer
□Glaucoma
□Stomach Ulcer
□Kidney Disease
□Anemia
□Tuberculosis
□AIDS or HIV
□Stroke
□Bleeding Tendency
□Mitral Valve Prolapse
□Rheumatic Fever
□Asthma
□Thyroid Disease
□Diabetes
□Hepatitis
□High Blood Pressure
□Other
□NONE
Review of Systems:
Do you have or have you had within the past year:
□Weight Change
□Dry Eyes
□Swollen feet/ankles
□Skin Rash
□Seizures
□Joint/Muscle Pain
□Chest Pain
□Depression
□Jaundice
□Easy Bruising
□Chronic Cough
□Chronic Diarrhea
□Swollen Lymph Nodes
□Easy Bleeding
□Rapid Heartbeat
□NONE
Women only:
Age period began_____________
Date of last mammogram ____________________
Do you do regular breast self-exams____________
# of Pregnancies
_
Did you breastfeed ___________
Breast lump or discharge ________
I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE. THIS FORM MUST BE COMPLETED BEFORE SEEING THE DOCTOR.
Patient Signature/Guardian
Medical History Form 09-2015
Date