Medical History Form Page 2
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1
2Medical History
Name ___________________________________
Date:
________________________
Please List and Supply the Dates of:
Operations ____________________________________ ______________________________ ____________________________
____________________________________________ _____________________________________ ___________________________________
Hospitalizations other than for surgery
_____________________________ ____________________________
____________________________________________ ____________________________________
___________________________________
Immunization history – have you had:
Pneumovax immunization?
No
Yes When? ___________
Hepatitis B?
No
Yes When? ___________
Flu immunization?
No
Yes When? ___________
Other?
No
Yes When? ___________
Tetanus immunization?
No
Yes When? ___________
When was your last:
Pap Smear? _______________ Breast Exam? _____________ Colonoscopy? _____________Bone Density Scan? ___________
Mammogram? _________Dental Exam? _________Cholesterol check? ________ Eye exam? ________Prostate exam? ________
Family History Has any member of your immediate family (including parents, grandparents, and siblings) ever had the following?
Illness
Which family member
Age when diagnosed
Cancer (describe type)
_____________________________________________ _________________________
Hypertension
_____________________________________________ _________________________
Heart Disease
_____________________________________________ _________________________
Diabetes
_____________________________________________ _________________________
Strokes
_____________________________________________ _________________________
Mental disease (anxiety, depression, etc)
_____________________________________________ _________________________
Drug or alcohol addiction
_____________________________________________ _________________________
Glaucoma
_____________________________________________ _________________________
Bleeding disease
_____________________________________________ _________________________
Other
_____________________________________________ _________________________
Prevention
Feel free to bring up issues you wish to discuss.
Do you wear seat belts?
Yes
No
If no, why not? _________________________________
Do you wear a bike helmet?
Yes
No
n/a
Do you exercise regularly?
Yes
No
If yes, type, duration and number of times
per week? __________________________________
Do you smoke?
Yes
No
If yes, how many packs per day? ___________________
Do you drink alcoholic beverages?
Yes
No
If yes, how much per week? _______________________
Do you drink coffee?
Yes
No
If yes, how many cups per day? ____________________
Do you drink tea?
Yes
No
If yes, how many cups per day? ____________________
If there is a gun in your home, do you keep it
unloaded and out of children’s reach?
Yes
No
n/a
Do you use drugs? (marijuana, cocaine, crack, etc.)
Yes
No
If yes, explain: _________________________________
Have you ever engaged in any activity which has
put you at risk of getting AIDS?
Yes
No
If yes, explain: _________________________________
Do you wish to be tested for AIDS?
Yes
No
Have you ever worked with chemicals, paints,
asbestos, or other hazardous materials?
Yes
No
Are you in a relationship in which you have been physically hurt (e.g., slapped, kicked, punched, bruised) by your partner?
Yes
No
Do you ever feel afraid of your partner?
Yes
No
n/a
Do you have a “living will?”
Yes
No
Do you have a donor card?
Yes
No
Do you wear sunscreen?
Yes
No
This information is for use by the physician as part of your confidential medical record.
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