Medical And Family History Form
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2MEDICAL & FAMILY HISTORY FORM
Please fill out this form completely prior to your visit with the physician. This is a confidential record
of your medical history and will be kept in this office according to our privacy policies.
PATIENT NAME: ______________________________
DATE OF BIRTH: ________________________
PATIENT/RESPONSIBLE PARTY SIGNATURE______________________________ DATE _____________
Main problem for today’s visit ___________________________________________________________
PAST MEDICAL HISTORY
Please check all that apply:
None
Diabetes
Liver Disorder
Anemia
Heart Disease
Lung Cancer
Anxiety disorder
Hepatitis Type _____
Osteoporosis
Arthritis, Degenerative
HIV
Renal Failure
Arthritis, Rheumatoid
Hypercholesterolemia
Skin Cancer
Asthma
Hypertension
Skin Disorder
Bleeding Disorder
Hyperthyroidism
Systemic Lupus
Traumatic Injury
Blood Transfusions
Hypothyroidism
Breast Cancer
Immune Deficiency
Urinary Incontinence
Colon Cancer
Gastrointestinal Disorder
Urinary Tract Infection
Coronary Artery Disease
Joint Disorder
Other__________________
Depression
Kidney Disorder
PAST SURGICAL HISTORY
Please check all that apply and list the year of occurrence:
None
Gallbladder Surgery
________
Appendectomy
________
Hysterectomy
________
Adenoidectomy
________
Joint Surgery/ Replacement
________
Cardiac Surgery
________
Sinus Surgery
________
Colonoscopy
________
Splenectomy
________
Ear Surgery
________
Tonsillectomy
________
Ear Tube Placement
________
Other Surgery/Hospitalization ________
MEDICATIONS
Please list all medications you are currently taking or attach a list with this form:
None
Medication __________________
Dosage _____________
How Often _______________
Medication __________________
Dosage _____________
How Often _______________
Medication __________________
Dosage _____________
How Often _______________
ALLERGIES
Please check all that apply:
Eggs
Sulfa
None
Demerol
Iodine
Latex
Aspirin
Penicillin
Other __________
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