TODAY’S DATE: __________________________
PATIENT NAME: ________________________________ DATE OF BIRTH: ______________
Do you have an Advanced Directives and Power of Attorney for Health Care? _______ If not, would you like
us to provide you with this information?
Yes
No
MEDICATIONS YOU ARE CURRENTLY TAKING:
Medication and dosage:
When started:
Reason for Medication:
__________________________
____________
_______________________________
__________________________
____________
_______________________________
__________________________
____________
_______________________________
__________________________
____________
_______________________________
__________________________
____________
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SURGICAL HISTORY (List approximate year done)
 Gall Bladder  Tonsils
 Appendix
 Uterus/Ovaries
 Hernia
 C-Section
 Coronary Bypass / Angioplasty
 Other (please list): _______________________________
__________________________
__________________________
__________________________
Please mark with an (X) any of the following illnesses and medical problems you have or have had and
indicate the year when each started. If you are not certain when an illness started, write down an
approximate year. For any additional comments/explanations, use the back page.
ILLNESS
X
Glaucoma

Other eye prob 
Hearing loss

Bronchitis

Emphysema

Pneumonia

Allergy

Asthma

Tuberculosis

Other lung prob 
Hypertension

Heart attack

Blocked arteries (heart,
carotid, legs) 
Rheumatic Fever 
Heart murmur

Other heart cond 
YEAR
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
ILLNESS
X
Stomach /duodenal
ulcer

Diverticulosis

Colitis

Gall Bladder

Gout

Yellow jaundice 
Liver trouble

Hepatitis

Hernia

Hemorrhoids

Kidney/bladder Dz 
Kidney stones

Prostate problem 
Migraines

Epilepsy/seizures 
HIV

YEAR ILLNESS
Blood Clot
_____ Thyroid disease
_____ Head injury
_____ Stroke
_____ Arthritis
_____ Cancer or tumor
_____ Sickle Cell
_____ Bleeding tendency
_____ Anemia
_____ Diabetes
_____ Skin conditions
_____ Mental Illness/
_____
depression
_____ Measles, Mumps
_____ Chicken pox
_____ Blood transfusion
_____ Alcoholism
X











YEAR
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____





_____
_____
_____
_____
_____
MEDICAL ALLERGIES
Are you allergic to any drugs (eg., Penicillin, Sulfa, Aspirin, I.V. Dye, etc.) tape, medical products (e.g.
Latex, Contrast Die, etc.) or animals? _____ YES
_____ NO
List allergy and reaction:
Allergy:
_________________
_________________
_________________
Reaction:
________________________________________________
________________________________________________
________________________________________________
Patient Name: ___________________________________
Date: ______________________
Place an "X" next to the test you have had done and list when and where:
When done:
Where test was performed:
Colonoscopy
EKG
Chest X-ray
Echocardiogram
Stress Test
Arterial Doppler
Venous Doppler
Carotid Doppler
Other
Habits
Do you currently smoke? ____Yes
____No
How many years?__________________
Do you chew tobacco?
____Yes
If yes, how much per day?___________________
Are you a former smoker?___________________
____No
Consumption of Alcoholic Beverages? ____Yes ____No
Amount:
_________oz
#______ of drinks per week / month / year
Do you currently use drugs: ____Yes ____No
Type:_________________________
Frequency:_____________________
Have you ever used drugs: ____Yes ____No
Type:_________________________
Frequency:_____________________
Coffee / Tea? ____Regular ____Decafinated ____None
Do you exercise regularly? ____Yes ____No
Number of cups per day:____________________
How often:________________
Type of exercise:_____________________
Are there any health resks involved in your job, home environment, or activities? ____Yes ____No
If yes, please
explain:______________________________________________________________________________________________
Sexual History
(The purpose of these questions is to determine your risk factors)
Are you currently sexually active?
_____ Yes _____ No
Do you currently have more than 1 partner?
_____ Yes _____ No
Any history of sexually transmitted disease?
_____ Yes _____ No
Are you now or have ever been tested for:
_____ HIV _____ Hepatitis C
_______ I would rather discuss this with the doctor in person.
Family Health History
Have any family relatives (mother, father brother, sister, grandfather, grandmother, aunt, uncle, cousin, nephew, niece, son,
daughter) suffered any of the following? Please list the people relative to their relationship to you:
Condition
Cancer
Relationship to you
Condition
Nerve/Muscle diseases
Obesity (overweight)
Seizures (fits, epilepsy)
Heart trouble
Stroke
Asthma or hayfever
Allergies
Diabetes (sugar)
Ulcers
Stomach or bowel problems
Gout
Kidney disease
Arthritis
Anemia (low blook)
Bleeding problems
Rheumatic fever
Alcoholism
Mental Illness
Physical deformity
Blind/deaf
Congenitally Impaired (Mental Retardation):
Other:
Relationship to you
Patient Name: _____________________________________ Date: ________________________
Place a mark in the box for each item that you have now or have had in the past and where applicable,
please fill in additional information.
GENERAL/
 weakness
 chills
 change in weight or appetite
CONSTITUTIONAL  fatigue
 night sweats
 fevers
 change in sleeping
habits
SKIN
 itching
 rash
 change in color
 easy bruising
 new or changing moles or other growths on skin
 headache
NERVOUS
 double vision  dizziness
 numbness/tingling
SYSTEM
 muscle weakness
 tremor/handshaking
 loss of coordination
CARDIOVASC.  chest pain  trouble breathing at night
 easy fatigue
SYSTEM
 palpitations (heart pounding)
 trouble climbing stairs
RESPIRATORY
SYSTEM
 blood clots/phlebitis
 ankle swelling
 wheezing
 frequent or chronic cough
 frequent bronchitis
 shortness of breath, with minimal exertion
GASTROINTESTINAL
 stomach pain/abdominal pain
 indigestion/heart burn
 black, tarry stools
URINARY
 urgency
 pain with urination
 previous infections
 blood in urine
 frequent urination
 loss of control of bladder
EYES
 glasses/contacts
 eye pain
EARS
 loss of/or decreased hearing
 excessive tearing
 blurring or spots
NOSE/THROAT/
SINUSES
 taste or smell changes
 frequent sore throats
JOINTS & BACK
 pain
MUSCLES
 pain
ENDOCRINE
 excessively hot
 always hungry
HORMONE/
 easy bruising
 difficulty swallowing
 vomiting/nausea
 diarrhea/constipation
 changes in bowel habits
 blood in stools
 loss of control of bowels
 difficult starting stream
 weak stream  leaking urine
 last eye exam date: __________
 double vision
 ringing in ears
 drainage
 hoarseness
 sinus problems
 neck swelling  last dental exam: __________
 swelling
 stiffness
 deformity
 weakness
 twitching
 cramping
 always thirsty
 excessively cold
 easy bleeding  swollen glands
LYMPH
ALLERGIES/  hives
 hay fever
 drug allergies: ____________________________________
IMMUNE
 other allergies: _________________________________________________________
PSYCHOLOGICAL
 nervousness
 depression
 unable to sleep
 nightmares
 memory loss
 anorexia/bulimia
 mood swings/anxiety
IMMUNIZATIONS
 Tetanus date: ___________  Influenza date: __________
 Chicken Pox date: __________  German Measles date: __________
 Pneumococcal date: __________  Hepatitis B Series date: ___________
MALES
 hernia
 pain in testicles
 sexual difficulties
 discharge from penis
SIGNS, SYMPTOMS AND DISEASES NOT COVERED ABOVE (additional space on back)
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