Medical History Form - Oregon Medical Group Page 3
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4Oregon Medical Group
Medical History Form
Today’s Date _____________ Patient Name ________________________________ Date of Birth ______________
FAMILY HISTORY
If Living:
If Deceased:
Relation
Cause
Age
Age at Death
Father
Mother
Brother or sister
1.
2.
3.
4.
5.
Has any of your immediate family ever had: (if yes, indicate relationship and age of onset)
Allergy/Asthma
Arthritis/Gout
Cancer
Depression
Diabetes
Epilepsy/Seizures
Glaucoma
Heart Disease/Coronary Artery Disease
High Blood Pressure
Liver Disease
Kidney Disease
Mental Illness
Alcohol/Substance Abuse
Migraine Headaches
Overweight
High Cholesterol
Stroke
Thyroid Disease
Tuberculosis
Ulcers
Bleeding Disorder
Colon Polyps
Other family medical history: ___________________________________________________________________________
For Clinician Use
Page 3 of 4
4032-00 12/09
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