Medical History Form - University Of Maryland University Health Center
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1
2UNIVERSITY OF MARYLAND
UNIVERSITY HEALTH CENTER
HEALTH HISTORY FORM
Name: _____________________________________________ University ID #: __________________________ Date: ___________
Gender: □ Male
□ Female
□ Transgender (MTF)
□ Transgender (FTM)
□ Other: ___________________________________
Phone #: ___________________________ Marital Status: _______________ Date of Birth: _________________ Age: ___________
Local Address: _______________________________________________________________________________________________
Drug allergies
: _______________________________________________________________________________
(list name and reaction)
Medications
: ____________________________________________________________________________
(prescription, over-the-counter)
PERSONAL HISTORY
Please explain in the space provided if you answered “yes”.
Yes
No
Unsure
Yes
No
Unsure
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Headaches/Migraines/Epilepsy/Seizures
Skin/Hair Problems
(Acne, Rashes, etc.)
_______________________________
_______________________________
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Lung Disease
Cancer
(Asthma, Tuberculosis, etc.)
(list type)
_______________________________
_______________________________
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Heart Disease
Birth Defects/Disabilities
(High Blood Pressure, Murmurs, etc.)
_______________________________
_______________________________
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High Cholesterol
Mental/Behavioral
(Depression, Anxiety, ADHD, etc.)
_______________________________
_______________________________
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Stroke/Blood Clots
Other Illnesses/Injuries
_______________________________
_______________________________
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Stomach or Intestinal Problems
Surgery
(Reflux, Crohn’s
(Tonsils, Wisdom Teeth, Appendix, etc.)
disease, Gluten/Lactose intolerance, Irritable bowel, etc.)
_______________________________
_______________________________
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Liver Disease
Hospitalization
(Mononucleosis, Hepatitis, Jaundice, etc)
(admitted overnight)
_______________________________
_______________________________
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Are you concerned about your weight/eating habits?
Gallbladder Disease
_______________________________
_______________________________
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Urinary Problems
Do you participate in a regular exercise program?
(Infections, Kidney Stones, etc.)
_______________________________
_______________________________
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Joint, Muscle or Bone
Do you smoke cigarettes? How much per day?
(Scoliosis, Fractures, etc.)
_______________________________
_______________________________
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Blood Problems
Do you drink alcohol? How much per week?
(Anemia, Clotting, Sickle Cell, etc.)
_______________________________
_______________________________
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Endocrine Problems
Have you ever used or taken any illegal drugs or
(Diabetes, Thyroid, PCOS, etc.)
_______________________________
medications that were NOT prescribed for you?
(Marijuana, Cocaine, Heroin, LSD, Shrooms, Ecstasy,
Adderall, Oxycontin, Other?)
_______________________________
FAMILY HISTORY
□ Adopted
Please list which family members (father, mother, siblings, grandparents, etc.) in the space provided if you answered “yes”.
Yes
No
Unsure
Yes
No
Unsure
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Lung Disease (Asthma, Tuberculosis, etc.)
Stroke
_______________________________
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High Blood Pressure
Blood Clots
_______________________________
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Heart Attack BEFORE age 50
Breast Cancer
_______________________________
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Other Heart Disease
Other Cancer(s)
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High Cholesterol
Birth Defects/Genetic Traits
_______________________________
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Diabetes
Mental Illness
_______________________________
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Thyroid Disease
Other Significant Family History
_______________________________
_______________________________
PLEASE COMPLETE THE REVERSE SIDE
Revised 6.15
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