Medical History Form printable pdf download

Medical History Form

Today’s Date

: _____________________

Name

Date of Birth

Age: _____________

: ________________________________________

: __________________

Marital Status

Occupation

Education

: _________________

: __________________________

: ____________________

Handedness:  Right  Left

Physician who referred you: _______________________________

Please describe the main problems/concerns that bring you to see us:

________________________________________________________________________________________________________

 Yes  No

Have you had other tests for this problem?

If yes, specify

:_______________________________________________________________________________

It started:  gradually  suddenly  off & on

When did the problem start?

________________

Has the problem changed over time?  Yes  No

If yes, better or worse? (circle one)

 Yes  No

Have you had any recent major life changes or stressors?

If yes, specify: ____________________________________________________________

Have you ever been treated for depression/anxiety, or other psychiatric conditions?  Yes  No

If yes, specify: _____________________________________________________________

List past surgeries:

________________________________________________________________________________________________

List names of current medications:

Name of medication

Dosage

Times per day

Prescribing Doctor

Example: Lasix

20mg

Twice a day

Dr. Jones

Living situation:  Home  Staying with relative ______________  Assisted living  Other ______________

Do you depend on anyone else to help out with household activities?  Yes _________________  No

Do you drink alcohol?  Yes  No

If yes, how much? ____________________

Is this problem related to any litigation, insurance claim, or application for disability?  Yes  No

Medical History Form

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