Medical History Form printable pdf download

Please fill out this form completely and legibly. Leave nothing blank.

If something does not apply, write “N/A” on the line.

Personal Contact Information

Today’s Date _________

Name _____________________________________________________ Age _______Date of Birth __________

Address ______________________________ City ________________ State _______Zip Code _____________

Home Phone _____________

Height _________

Weight _________

Sex (Circle one):

Work Phone _____________

Employer _______________________________________________________

Cell Phone _______________

Occupation _____________________________________________________

Email _____________________________________________________________________________________

Marital Status (Circle one): Single

Partnered

Married

Divorced Widowed

Number of Children ____

Emergency Contact:

Name ______________________________________Phone __________________

Relationship to Patient ________________________________________________

Medical History

Do You have any history of (Check all that apply):

❏ Heart disease

❏ Cancer

❏ Stroke

❏ Diabetes

❏ Hypertension

❏ Low blood sugar

❏ Low blood pressure

❏ Liver disease

❏ Dementia

❏ Alzheimer’s

❏ Parkinson’s

❏ Concussion

❏ Head injury

❏ Depression

❏ Mental illness

❏ Other ________________

Elaborate on any Family history of the above:___________________________________________________

__________________________________________________________________________________________

Have you ever had any broken bones?

❏ Yes

❏ No

Which bone(s) and when? __________________________________________________________________

Any long-term effects? _____________________________________________________________________

Have you ever had any surgeries?

❏ Yes

❏ No

Please list any surgical procedures and their respective dates: _____________________________________

__________________________________________________________________________________________

When was your last physical exam? ____________________________________________________________

Results: __________________________________________________________________________________

__________________________________________________________________________________________

Results of latest lab work? ____________________________________________________________________

Nutrition and Exercise History

Do you smoke?

❏ Yes ❏ No

Have you ever smoked?

❏ Yes ❏ No

If Yes, Cessation date _________________________________

Do you drink Alcohol?

❏ Yes ❏ No

If Yes, How much and how often? _______________________

Are you a Vegetarian?

❏ Yes ❏ No

If Yes, What kind? ____________________________________

How many meals do you eat per day? ________How often do you eat out? ____________________________

What type of food do you eat when eating out? _________________________________________________

Do you exercise regularly?

❏ Yes ❏ No

If Yes, What kind of exercise and how often? ______________

__________________________________________________________________________________________

List all medications, vitamins and supplements that you are currently taking: __________________________

__________________________________________________________________________________________

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Medical History Form

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