Medical History Form
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2MEDICAL HISTORY FORM (for Adults > 17 years old)
Mark D. Freedman, MD
Name _________________________________________________
Birth date ____/____/_______
Where were you born? _______________________How long have you
lived in the Chicago area? _________
Married
Single
Divorced
Widowed
Who lives with you in your home? (list all)
________________________________________________________
Where do you work? __________________________Occupation _________________________
What is the main reason for this visit? _______________________________________________
How were you referred to Dr. Freedman? ____________________________________________
PAST HISTORY
Any unusual or severe childhood diseases? ___________________________________________________
Any surgeries / operations ?(
)____________________________________________
please give date and place
_______________________________________________________________________________________
______________________________________________________________________________________
Any bad accidents / broken bones? _________________________________________________________
______________________________________________________________________________________
Hospitalized for any illnesses? (
)__________________________________________
please give date and place
______________________________________________________________________________________
______________________________________________________________________________________
Pregnant in past?
HOW MANY PREGNANCIES? _______ NORMAL DELIVERIES? _______ CESAREAN DELIVERIES?_____
MISCARRIAGES or ABORTIONS? _______ MEDICAL PROBLEMS with PREGNANCIES? ______________________________
Taking any prescribed medications? _________________________________________________________
_______________________________________________________________________________________
Any over-the-counter medications or supplements? _____________________________________________
_______________________________________________________________________________________
Allergic to any medications? ________________________________________________________________
Allergic to any other substances? _____________________________________________________________
Last visit to a doctor WHEN? ____________ WHO? _________________________ _____________________
REASON_________________________________________________________________________________
LAST PAP SMEAR ___________RESULTS_____________________________________________________
LAST MAMMOGRAM _______________ RESULTS ______________________________________________
LAST CHOLESTEROL TEST __________ RESULTS ______________________________________________
LAST COLONOSCOPY ______________RESULTS _______________________________________________
CARDIAC STRESS TEST ______________ RESULTS ____________________________________________
CURRENT STATUS
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Have you gained or lost a lot of weight in the past year?
yes
no
How much? ________________
Are you following any special diet? (explain)_________________________How is your appetite?_________
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Do you exercise or play sports?
Always, ____ times per week
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What do you do or play? ________________________
Occasionally, _____ times per month
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Never
Any problems with your bowels? ______________________________________________________________
Any problems with urination? _________________________________________________________________
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Are you sexually active? _____
Homosexual
Heterosexual
How many partners in the last year? _____
Any problems with sexual function? ____________________________________________________________
Any sexually-transmitted diseases in the past? ___________________________
Do you use any form of contraception or protection? ______________________________________________
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Are you menstruating regularly?
How often?
every 21-25 days
26-35 days
> 35 days
YES
NO
When was the first day of your last menstrual period? _________________________________
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Have you felt depressed in the last month?
Been treated for depression in the past?
YES
NO
YES
NO
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Do you smoke tobacco?
used to (date you quit ____________)
YES
How much?______________
NO
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Drink alcohol?
YES How much? ___________________________________ [beer]
[wine] [other]
NO
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Use marijuana?
Cocaine?
YES How much? _____________
NO
YES How much? ____________
NO
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Any other drugs?
Which ones? ______________________
YES
How much? ___________________
NO
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