Medical History Form - Duke Health

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DUKE PRIMARY CARE
HEALTH HISTORY
Name: ________________________________________ Sex □ Male □Female Date__________________
Date of Birth ____/____/____Marital Status: □ Married □ Single □ Separated □ Divorced □ Widowed
Do you have any health concerns? If yes, please list
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PAST MEDICAL HISTORY: Check conditions that doctors have followed you for in the past:
□ High blood pressure/hypertension □ High Cholesterol
□ Liver Disease
□ Diabetes (“sugar”)
□ Thyroid Problems
□ Kidney Disease
□ Heart Attack/By-pass Surgery
□ Heart Failure
□ Heart Murmur
□ Mitral Valve Prolapse
□ Stroke
□ Seizures/Epilepsy
□ Stomach Problems □ Intestinal Problems
□ Reflux Disease
□ Glaucoma
□ Psychiatric Illness □ Arthritis
□ Abnormal PAP
□ Cancer: Type & Location __________________________________________________________________
□Other:___________________________________________________________________________________
Have you ever had: Positive Tuberculosis Test □Yes □No
Rheumatic Fever
□Yes □No
Blood Transfusion
□Yes □No
List any hospitalizations or surgeries you have had (including C-section):
__________________________________________________________________________________________
__________________________________________________________________________________________
List any drug allergies:
__________________________________________________________________________________________
Are you allergic to latex? Yes
No
List all current medications (including vitamins, herbal, and health food preparations) :
_____________________________ _____________________________ ___________________________
_____________________________ _____________________________ ____________________________
_____________________________ _____________________________ ____________________________
PREVENTATIVE CARE: When was your last:
Tetanus Booster __________ Flu Shot ________ Pneumonia Vaccine _________Hepatitis Vaccine________
Flexible Sigmoidoscopy/Colonoscopy _____________________________
Bone Densitometry___________
Female Only: How often do you examine your breasts? ___________ Do you see an OB?GYN doctor?______
When was your last mammogram?____________________ When was your last PAP smear?_______________
Male Only: Do you do a testicular exam? _________ Do you have any problems with erections? ____________
When was your last: prostate blood test (PSA) ____________ Prostate/rectal exam? _____________________
PLEASE COMPLETE BACK OF FORM

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