Medical History Form Page 2
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2Family Medical History: Please list major illnesses that affect immediate family:
MEDICAL ILLNESS
RELATION MEDICAL ILLNESS
RELATION
1)
5)
2)
6)
3)
7)
4)
8)
Social History:
Alcohol use:
Yes
No
Drinks per week: ________
Cigarette use:
Yes
No
Packs per day:_________
Years: ______
Smokeless Tobacco use:
Yes
No
Years: _______
Illicit Drug use:
Yes
No
Type: _________________
Review of Symptoms: Please mark any of the symptoms that apply to you TODAY:
SYMPTOM
YES
NO
SYMPTOM
YES
NO
Tarry Stools
Frequent Urination
Vomiting
Urgent Urination
Abdominal Pain
Painful Urination
Chest Pain
Muscular Weakness
Irregular Heart Beat
Numbness or Tingling
Rapid Heart Beat
Joint Pain or Swelling
Swelling of Legs
Muscle Pain or Swelling
Cough
Frequent/Easy Bruising
Shortness of Breath
Cuts that don’t stop Bleeding
Rash
Anxiety
Wound Healing Problem
Depression
Fever/Chills
OTHER:
Agreement of Accuracy : The information provided in this history form is true and
complete to the best of my knowledge.
x ___________________________________
Date: ____________
How were you referred to our practice?
(circle)
Friend/Relative: ______________
Physician
Newspaper
Radio
Website
Other: _____________________
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Parent category: Medical