Medical
H istory
F orm
Patient
N ame:
_ ____________________________________________________________
Date
o f
B irth:
_ _____________________
Today’s
D ate:_______________________
Current
w eight:
_ __________________
Current
h eight:
_ ___________________
Reason
f or
V isit:
_ _______________________________________________________________
q
q
q
How
D id
Y ou
H ear
A bout
U s?
q
D octor
R eferral
I nternet
F riend
R eferral
S ocial
M edia
( e.g.,
Y elp)
q
O ther
_ __________________________________
SOCIAL
H ISTORY
Do
y ou
s moke?
Yes
No
If
y es,
h ow
m any
p acks
p er
d ay?
_ _______________________________
Have
y ou
e ver
s moked?
Yes
No
For
h ow
m any
y ears?
_ ___________________________________________
Do
y ou
u se
a ny
s treet
d rugs?
Yes
No
Do
y ou
d rink
a lcohol?
Yes
No
If
y es,
h ow
m any
d rinks
( average)
p er
w eek?
_ ________________
Do
y ou
e xercise
r egularly?
Yes
No
If
y es,
h ow
m any
t imes
( average)
p er
w eek?
_ _________________
PHARMACY
I NFORMATION
Pharmacy
N ame:
_ _________________________________________________________________
Tel:
_ ____________________________________
Address:
_ __________________________________________________________________________
MEDICATIONS
A ND
S UPPLEMENTS
Please
l ist
a ll
m edications
a nd
s upplements
y ou
a re
c urrently
t aking.
Name
o f
M edication
Dose
a nd
F requency
Reason
f or
t aking
Do
y ou
t ake
a ny
b lood
t hinners?
____
N o
____
C oumadin
____
A spirin
____
O ther:
_ ______________________________
ALLERGIES
_____
I
h ave
n o
k nown
a llergies
_____
I
h ave
t he
f ollowing
a llergies:
Medication/Substance
Reaction
FAMILY
H ISTORY
Does
o r
d id
a nyone
i n
y our
f amily
h ave
a ny
o f
t he
f ollowing
c onditions?
Condition
Relationship
Description
q
C ancer
q
B leeding
o r
c lotting
d isorders
q
D iabetes
q
H eart
a ttack
q
S troke
q
O ther
(Please
t urn
t o
o ther
s ide.)