Medical History Form printable pdf download

Medical History

Date:

PLEASE PRINT AND COMPLETE ALL INFORMATION

______________________________

Name: _________________________________________________________ Date of Birth: ______________________________

Last

First

Middle

Occupation: ____________________________________________

Married

Single

Widowed

Divorced

Separated

If married, spouse’s name: _____________________________ Pharmacy Name and Phone: _______________________________

Children’s names and ages: ___________________________________________________________________________________

Allergies to Medications, X-Ray Dyes, or Other Substances

Yes

If yes, please list name of medicine and type or reaction

_______________________________ ________________________________ _______________________________ _________________________________

Medications (Prescription, Over-the-Counter, Vitamins, Herbs, etc.)

Drug Name

Dose

Drug Name

Dose

Drug Name

Dose

___________________________________________ __________________________________________ __________________________________________

Past Medical History and Review of Systems:

Please check off if you have had any problems with or are presently experiencing any of the following:

Alcohol abuse

Depression

Hepatitis or jaundice

Pneumonia

Abdominal discomfort

Diarrhea

High Blood Pressure

Rheumatic fever

Anemia

Diabetes

High Cholesterol

Shortness of breath

Anxiety

Difficulty urinating

Impotence or

Skin diseases

Arthritis

Drug abuse

Erectile Dysfunction

Swollen ankles

Asthma

Emphysema

Indigestion

Tuberculosis

Blood disorders

Frequent urination

Kidney disease

Thyroid disease

Blood in stool

Gall Bladder disease

Kidney stones

Ulcers

Bronchitis

Gout

Lightheadedness

Unexplained weight

Cancer

Hay fever

Low back problems

gain/loss

Change in bowel habits

Head or neck radiation

Nausea

Venereal disease

Chest pain/chest tightness

Headache

Palpitations

Vomiting

Colitis

Heart Disease

Persistent cough

Other _____________

Constipation

Hemorrhoids

Chicken Pox

____________________________________________________________________________________________________________________________________

Gynecologic and Obstetric History

Gynecologist: _______________________

Age at onset of periods _____________________

Frequency ________________________

Length of period ______________

Pregnancies _____________________________

Births ___________________________

Miscarriages _________________

Prolonged or abnormal bleeding