MEDICAL HISTORY FORM
Name: ___________________________________
Current Status:
Married
Single
Other
__________________
Children Names/Ages:
DOB: _
Adopted:
Y
N
_____________________________
Employer:
____________________________
Occupation:
Please check if you currently have or have had any of the following:
Immunizations:
Asthma
Hypertension
Depression
Psychiatric Disorder
__________
Last Tetanus:
Hepatitis B
Seizures
Blood Clots
Bleeding Disorder
_________
Last TB:
Positive:
Y
N
Hepatitis C
Heartburn
Diabetes
Heart Disease
__________
Hepatitis A Series:
Ulcers
Hayfever
Migraines
Elevated Cholesterol
__________
Hepatitis B Series:
Urinating Difficulties
Thyroid Disease
Cancer
__________
Other Please specify: _________________
Flu:
Comments: _________________________________________
Medications:
Date of Last Preventative:
List medications and dose you are currently taking.
______
Colonoscopy: Year
Normal?:
Y
N
Include vitamins and herbal supplements.
______
Pap: Year
Normal?:
Y
N
Check if no medications.
______
Mammograms: Year
Normal?:
Y
N
______
Dexascan: Year
Normal?:
Y
N
Please mark any past surgeries and/or hospitalizations,
indicate which by marking an S or H.
Back___(S/H) Sinus___(S/H) Tonsils___(S/H) Bones___(S/H)
Allergies:
Hernia___(S/H) Appendix___(S/H) Vasectomy___(S/H)
Gall Bladder___(S/H) Tubal Ligation___(S/H)
Hysterectomy ___(S/H) Ovaries Removed? (Y/N)
___________________________
Other/Comments:
Preferred Pharmacy? ______________________
Family History: (Blood Relatives Only)
Father:
Present Health or Cause of Death
Age?
Alive
Deceased
Y
N Tobacco _____________________ (packs/day)
Mother:
Present Health or Cause of Death
Age?
Former Tobacco User ________________ (date quit)
Alive
Y
N Alcohol ____________________ (drinks/week)
Deceased
Y
N Recreational Drugs ________________ (type)
Brothers:
Present Health or Cause of Death
Age?
Y
N Exercise ____________________ (times/week)
___# Alive
___# Deceased
Sexual Orientation:_____________________ (optional)
Sisters:
Present Health or Cause of Death
Age?
Religious Preference: ___________________ (optional)
___# Alive
Do religious beliefs impact your daily activities?
Y
N
___# Deceased
Comments: ___________________________________
Females Only:
immediate family members
Please check medical problems
Current method of Birth Control: ______________
have or have had in the past.
Has your husband had a vasectomy?
Y
N
Medical Complaints
Mother
Father
Siblings
Comments - Age?
Heart Attack
Total # of Pregnancies: ________
Diabetes
Live Births: ________
Glaucoma
Miscarriages/Abortions: ________
Cancer (list type)
Osteoporosis
Stroke
Please initial and date any updates made:
High Blood Pressure
Kidney Disease
___________________________________ (sign/date)
Brain Aneurysm
Blood Clots
___________________________________ (sign/date)
Colon Polyps
High Cholesterol
___________________________________ (sign/date)
Thyroid Disease
Depression
___________________________________ (sign/date)