Medical History Form printable pdf download

MEDICAL HISTORY FORM

NAME OF PATIENT_____________________________________DOB____________________

What prescription medicines do you take? __________________________________________

Are you allergic to any medications? _______________________________________________

When was your last: mammogram ________Colonoscopy__________ Blood Test _______

Immunizations _________________________________________________________________

Have you had any surgeries and when? ____________________________________________

Please list the medical conditions that you are being treated for now, or have been treated

for in the past (ex. High blood pressure, serious infections, problems with blood, nervous

system, heart, lungs, stomach, intestines, colon, liver, spleen, prostate, vision, hearing,

ovaries, uterus, etc) Please list any other reasons for hospitalizations not listed above:

Do you smoke? ______How many packs per day?______How old were you when you

started?______

Would you consider yourself a light, medium or a non-drinker? _____________

Please list names and ages of family members in your household: ______________________

Family History: Please list member of family or deceased member that may have/had the

following condition(s)

High Blood Pressure: ____________________________________________________________

Diabetes: ______________________________________________________________________

Heart Attack: __________________________________________________________________

Cancer of any type (including leukemia) ___________________________________________

Does anything else “run” in your family? ___________________________________________

WOMEN: How many times have you been pregnant?_________How many children do

you have?________What was the first day of your last menstrual period?_______________

Medical History Form