HPHS PATIENT MEDICAL HISTORY FORM – please complete this form in it’s entirety
Name: ______________________________________________
Date of Visit: _______________ Age: _________
Reason for today’s visit: ______________________________________________________
Left Right Bilateral
Referring Physician: __________________________________Family Physician: ________________________________
Other Physicians /specialists you are seeing: ______________________________________________________________
__________________________________________________________________________________________________
Medications, incl prescriptions, anti-inflammatory drugs or non-prescription medications
MED: _______________________ DOSAGE: ________
MED: _______________________ DOSAGE: ________
MED: _______________________ DOSAGE: ________
MED: _______________________ DOSAGE: ________
MED: _______________________ DOSAGE: ________
MED: _______________________ DOSAGE: ________
PHARMACY NAME: _________________________________ PHARMACY PHONE NO: ________________________
no yes If yes, please list below
LATEX ALLERGY:
no yes
__________________________________________________________________________________________________
DRUG ALLERGIES:
Medical History:
Have you ever had any of the following conditions? IF YES, PLEASE CIRCLE & EXPLAIN
Bleeding Problems (excess bleeding dvt blood clots)
no yes
________________________________________________________________________
Cancer (including skin cancer)
no yes
________________________________________________________________________
Endocrine (diabetes thyroid other)
no yes
________________________________________________________________________
Digestive (gastric reflux ulcers gallstones hepatitis colitis other)
no yes
________________________________________________________________________
Heart Disease (chest pain arrhythmias heart attack heart failure high blood pressure
peripheral vascular disease other)
no yes
________________________________________________________________________
Infectious Disease (HIV TB STD HCV chronic infections other)
no yes
________________________________________________________________________
Respiratory (asthma cystic fibrosis emphysema sarcoid other)
no yes
________________________________________________________________________
Neurologic (dementia depression seizures other)
no yes
________________________________________________________________________
Skin (severe acne eczema psoriasis skin cancer other)
no yes
________________________________________________________________________
Allergy/Rheumatology (arthritis lupus/scleroderma fibromyalgia other)
no yes
________________________________________________________________________
Urinary (bladder infections prostate kidney stones kidney disease other) no yes
________________________________________________________________________
Other Medical Problems
no yes
________________________________________________________________________
Surgical History: Please list any operations, including plastic surgery, you have undergone along with the dates:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Hospital Admissions: Please list any hospital admissions and reason for admissions:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
TURN PAGE OVER & FILL OUT BACK
2016
Review of Systems:
Constitutional: none
Eyes:
none
Ears:
none
Nose:
none
Neck:
none
Mouth/Throat: none
Heart/Lungs: none
Digestive:
none
Urinary
none
Muscular:
none
Skeletal:
none
Neurologic:
none
Psychiatric:
none
Skin:
none
Are you currently experiencing any of the following? If yes, circle
weakness fever weight loss weight gain
itching excess tearing change in vision or double vision
pain ringing buzzing imbalance loss of hearing
obstruction bleeding chronic drainage
stiffness swelling lumps
chronic sores pain difficulty swallowing
chest pain palpitations shortness of breath chronic cough
heartburn nausea/vomiting constipation diarrhea
incontinence retention bleeding
swelling weakness difficulty moving leg cramps
back pain joint pain stiffness
headaches migraines tremors numbness and tingling
anxiety depression hallucinations chemical dependency
lesions rashes lumps itching
Social History:
Occupation: ________________________________________________________________________________
Recreational Activities: _______________________________________________________________________
Smoking:
 current every day smoker  current some day smoker  former smoker  never smoked
Alcohol:
no
yes
Recreational Drugs: no
frequent
occasional
social
yes ______________________________________________________________
Family History: Please list any major medical problems with parents, grandparents, and/or siblings:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Height: ________________
Weight: ____________________
Date of Birth: ___________________
If pertinent, any recent X-rays, CT Scans or MRIs? no
yes
Date studies performed: _____________________ Location _________________________________________
If pertinent, any recent nerve conduction studies (EMG/NCV)?
no
yes
Date studies performed: _____________________ Location _________________________________________
Females: Date of last mammogram ___________________ Location _________________________________________
Anesthesia: Have you or anyone in your family had a problem with anesthesia:
no
yes
If yes please explain________________________________________________________________________
Patient’s Signature: ____________________________________________
Date: __________________________