Patient History Form
Name_____________________________________________________Date of Birth________________
First
Middle
Last
Referring Physician:_________________________ Primary Care Physician: ______________________
Why are you here today? _______________________________________________________________
Have you had any x-rays, ultrasounds, or CT Scans pertinent to today’s visit?
If so, did you bring a copy of the films with you today?
Yes or
No
YES NO
Where did you have the x-ray, ultrasound, CT, MRI, or other ___________________________
Allergies:
List any medications that you are allergic to and the reaction you have:
________________________________
_____________________________________
________________________________
______________________________________
________________________________
______________________________________
Other Allergies:
List any other allergies (bee stings, etc) ___________________________________
Medications (please list all your medications and their dosages)
Medication
Dosage
_____________________________________________
________________________________
_____________________________________________
________________________________
_____________________________________________
________________________________
_____________________________________________
________________________________
_____________________________________________
________________________________
_____________________________________________
________________________________
_____________________________________________
________________________________
_____________________________________________
________________________________
If you need more room use back of sheet
What Pharmacy do you use? ____________________________________________________________
Name and Location
Do you take any blood thinners, aspirin, Motrin, anti-inflammatories, Ibuprofen, or arthritis
medications? Y or N (if yes, please list)
Past Medical History
Have you ever had any of the following conditions?
Cardiovascular
Angina (chest pain)
Arrhythmia (irregular heartbeat)
Atrial Fibrillation
 Bleeding Disorder
Congestive Heart Failure
Coronary Artery Disease
Deep Vein Thrombosis (blood clot)
Heart Attack
Heart Valve Problems
Hypertension (High Blood Pressure)
Stroke
Endocrine/Metabolic
Diabetes not requiring Insulin
Diabetes requiring Insulin
Gout
Hyperthyroid (high thyroid)
 Hyothyroid (low thyroid)
General
High Cholesterol
Polycystic Kidneys
Sleep Apnea
Gastrointestinal
Crohns Disease
Diverticulitis
GERD / Acid Reflux
Hemorrhoids
Hepatic/Liver Failure/Cirrhosis
 Hepatitis
Irritable Bowel Disease
Pancreatitis
Peptic Ulcer Disease
Ulcerative Colitis
Cancer ________________________________
________________________________
Specify what type(s) cancer
Have you received the flu vaccination this year?
Genitourinary
AIDS
BPH (Benign Prostatic Hypertrophy)
Chronic Renal Failure
Elevated PSA
Fertility Problems
Hematuria (blood in urine)
HIV
Kidney Cancer
Kidney Stones
Prostate Cancer
Recurrent Urine Infection
Bladder Cancer
Venereal Disease
GYN/OB
Breast Cancer
Endometrosis
Ovarian Cyst
Uterine Fibroids
HEENT
Glaucoma
Mumps
Musculoskeletal
Arthritis
Back Pain
Fibromyalgia
Neuro/Psych
Alcoholism
Alzheimer’s
Parkinson’s
Seizures
Spinal Cord Injury
Respiratory
Asthma
COPD
Emphysema
Pulmonary Embolism
Tuberculosis
NO
YES
(when_______________________)
Any other conditions not listed above _____________________________________________________
Past Surgical History:
(check all the surgeries you have had and indicate the year you had the
surgery)
Cardiovascular
Angioplasty / Stents
Artificial Heart Valve
 Aortic Aneurysm
 Coronary Bypass
Carotid Artery Surgery
Pacemaker or Defibrillator
Gynecology
Cystocele Repair (dropped bladder)
Hysterectomy thru Abdominal Incision
Hysterectomy thru Vaginal Incision
Ovary Removal (one or both)
Rectocele Repair (dropped rectum)
Tubal Ligation
Incontinence Surgery
General
Brain Surgery
Laminectomy (Back Surgery)
HEENT
Cataract Surgery
Nasal Surgery
Thyroid Surgery
Tonsillectomy
Gastrointestinal
Appendectomy
Bariatric (obesity) Surgery
Bowel (intestine) resection
Cholecystectomy (Gall Bladder Removed)
 Colonoscopy
Inguinal Hernia Repair
 Ileostomy
Genitourinary
Nephrectomy (Kidney Removal)
Left Side
Right side
Kidney Stone Surgery
Penile Prosthesis
Prostate Biopsy
Prostate Radiation
Radical Prostatectomy (for prostate
Cancer)
Testicular Surgery
Enlarged Prostate Surgery
Artificial Urinary Sphincter
Musculoskeletal
Amputation
Back Surgery
Cervial Spine (Neck) Surgery
Hip Surgery
Joint Replacement Surgery
Which joint__________________
Knee Surgery
Shoulder Surgery
Skin
Respiratory
Melanoma
Lung
Surgery
Other Skin Cancer
Other Surgeries Not Listed
_______________________________
_______________________________
_______________________________
_______________________________
Have you been instructed by a physician to use special antibiotics before medical procedures
because you have a serious heart valve condition or rheumatic fever. If so, PLEASE list the
condition:
____________________________________________________________________________________
Last Menstrual Period _______________________
What are you currently using for birth control? __________________________________________
Women Only: Number of pregnancies ______________ Number of babies delivered ___________
Family History (check if any of your relatives have had)
Cancer – Other
Diabetes
Heart Attack
High Blood Pressure
Kidney Cancer
Kidney Failure
Kidney Stones
Prostate Cancer
Stroke
Social History
Marital Status: ____________ # of children: ___________
Do you use illicit drugs? YES NO
Occupation (If retired, list prior occupation) _____________
Do you drink alcohol?
YES NO
Do you use tobacco?
YES
Have you ever smoked?
NO
If yes, do you drink daily? If yes how much _______________
type: _________________ # of Packs per day: ______________
YES NO
If so, how many years ago did you quit? ____________
Review of Systems
Do you currently have any problems related to the following? Circle Yes or No. Please explain
any yes answers in the space provided.
Constitutional Symptoms
Fever
Weight Loss
Yes
Yes
Integumentary
No
No
Yes
Yes
No
No
Allergic/Immunologic
Hay Fever
Seasonal Allergies
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Sore throat
Sinus problems
Yes
Yes
No
No
Frequent Cough
Yes
Shortness of Breath Yes
No
No
Hematologic/Lymphatic
Yes
Yes
No
No
Gastrointestinal
Hepatitis
Yes
Blood Clot Problems Yes
No
No
Psychological
Bloody Stool
Yes
Indigestion/HeartburnYes
No
No
Cardiovascular
Chest Pain
Irregular Heartbeat
Gout
Muscle Cramps
Respiratory
Endocrine
Excess Thirst
Too Hot or Cold
No
No
Ear, Nose, and Throat
Neurological
Headache
Dizzy Spells
Yes
Yes
Musculoskeletal
Eyes
Blurred Vision
Glaucoma
Persistent Itch
Rash
Yes
Yes
No
No
Anxiety
Depression
Yes
Yes
No
No