Medical History and Intake form pg 1
Patient Name ___________________________
Marital Status:
Date of Birth:
Race :
Married
Divorced
Single
Widowed
Domestic Partner
Registered Domestic Partner
Interlocutory
Unmarried
___________
Gender:
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Ethnic Group:
Chart # _____________________ Date completed_______
Hispanic or Latin
Preferred Method of Contact:
Female / Male
Asian
White
Not Hispanic or Latin
Phone
Common Law
Living Together
Legally Separated
Annulled
Unknown
All Others
Preferred Language
________________
Black or African American Prohibited by state law
Declined to Specify
Other ______________________
Prohibited by state law
Declined to specify Other _____
Letter
Preferred Phone Number _____________________________________________
Pharmacy Name / Address / Phone#: ____________________________________________________________
PAST MEDICAL HISTORY
Past medical History (circle all that apply)
Anxiety
End Stage Renal Disease
Arthritis
GERD :Gastroesophageal Reflux Disease
Asthma
Hearing Loss
Atrial Fibrillation
Hepatitis
BPH (Enlarged Prostate)
Hypertension (High Blood Pressure)
Bone Marrow Transplantation
Hyperthyroidism (high)
Breast Cancer
Hypothyroidism (low)
Colon Cancer
Leukemia
COPD(Chronic Obstructive Pulmonary Disease)
Depression
Lung Cancer
Diabetes
Lymphoma
Pacemaker
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Valve Replacement
Other _______________
Other _______________
Other _______________
NONE
Past Surgical History (circle all that apply)
Appendix
Heart: Coronary Artery Bypass Surgery
Bladder (cystectomy)
Heart: PCTA
Breast: Mastectomy Right Breast
Heart: Mechanical Valve Replacement
Breast: Mastectomy Left Breast
Heart: Biological Valve Replacement
Breast: Mastectomy Both Breasts
Heart: Heart Transplant
Breast: Lumpectomy Right Breast
Joint Replacement: Right Knee
Breast: Lumpectomy Left Breast
Joint Replacement: Left Knee
Breast: Lumpectomy Both Breasts
Joint Replacement: Both Knees
Breast: Breast Biopsy
Joint Replacement: Right Hip
Breast: Breast Reduction
Joint Replacement: Left Hip
Breast: Breast Implants
Joint Replacement: Both Hips
Colon: Colectomy( Colon Cancer resection) Kidney: Kidney Biopsy
Colon: Colectomy(Diverticulits)
Kidney: Kidney stone removal
Colon: Colectomy (inflammatory Bowel Disease)Kidney: Kidney Transplant
Other :________________________________________________________________
Ovaries: Endometriosis
Ovaries: Ovarian Cyst
Ovaries: Ovarian Cancer
Prostate: Prostate Cancer
Prostate: Prostate Biopsy
Prostate: TURP
Skin: Skin Biopsy
Skin: Basal Cell Carcinoma
Skin: Squamous Cell Carcinoma
Skin: Melanoma
Spleen: (Splenectomy)
Testicles (Orchiectomy)
Uterus: Hysterectomy-Fibroids
Uterus: Hysterectomy-Uterine Cancer
NONE
History and intake Form Pg 2
Patient Name _______________________________
Pt chart # _______________________
Skin Disease History (please circle all that apply)
Acne
Actinic Keratoses
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaking or itchy scalp
Hay fever/Allergies
Melanoma
Poison Ivy
Precancerous Moles
Psoriasis
Squamous Cell Skin Cancer
Seborrheic Keratoses
Do you wear sunscreen? Yes / No
If yes, what SPF?
Do you tan in a tanning salon? Yes / No
Do you have a family history of melanoma? Yes / No
Rosacea
Warts
Cysts
None
Other _____________
__________________________
If yes which relative? ___________________________________________________________________________________
ALLERGIES: (Please enter all allergies)
Are you allergic to latex?
YES
NO
Drug Allergies: (list drugs you are allergic to):___________________________________________________________
___________________________________________________________________________________________________
Reactions to drug allergies (circle all that apply):
Anaphylaxis
Angiodema
Diarrhea
Fatigue
GI upset
Hives
Liver Toxicity
Rash Other _______________
Other allergies: _______________________________________________________________________________________
Social History: (Circle all that apply)
Sexual History:
Sexually active with one partner
Sexually active with a partner of the same sex
Sexually active with more than one partner
Not sexually active
Illicit Drug Use:
Drug use
IV Drug use
None
Alcohol use: None
less than 1 drink per day
1-2 drinks per day
3 or more drinks per day
Cigarette Smoking:
1.current every day smoker
2. Current some day smoker (tobacco)
3.Former smoker
4.Light tobacco Smoker
5. Heavy tobacco smoker
8. Smoker, current status unknown
6. current some day smoker(cigarettes) 7.Never smoked
Safety:
I feel safe at home
I do not feel safe at home
Driving Status:
I drive during the day
I drive at night
How often do you exercise?
Several times per day
Once per day
Few times per week
Few times per month
Never
Other
History and intake Form Pg 3
Patient Name _______________________________
Pt chart # ____________________
What is your caffeine use?
Several times per day
Once per day
Few times per week
Few times per month
Never
Other
Occupation and Workplace :
___________________________________________________________________________
Place of residence:________________________________________________________________________________
Other:______________________________________________________________________________________________
_
FAMILY HISTORY
Is there at family history of disease in your family? Yes
No
If yes, what disease(s) and which family members did this disease affect? (example mother, father, sister,
brother, daughter, son, aunt, uncle, nephew, niece, grandmother, grandfather, grandson, granddaughter, )
1. ________________________________________________________________________________
Disease
Family member(s)
2. ________________________________________________________________________________
Disease
Family member(s)
3. ________________________________________________________________________________
Disease
Family member(s)
4. _________________________________________________________________________________
Disease
Family member(s)
Other Family histories (please write in this space if needed)