Medical History Form - Duke Health Page 2
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2SOCIAL HABITS
Have you ever used tobacco products? □ Yes □No
Do you drink alcohol?
□ Yes □No
What kind? ______________________________
How many drinks per week? _______
How much? ______________________________
Have you ever felt you need to cut down? □ Yes □ No
For how many years? ______________________
Have you ever felt guilty about our drinking? □ Yes □ No
Date quit?________________________________
Do you use drugs? □ Yes □No What type?___________
How often?______________________________________
How many glasses/cups of caffeine do you drink daily? __________ Do you have guns in your home? ______
Do you exercise outside of your job?______Do you wear seatbelts? □ always □usually □ sometimes □ never
What is your occupation? _________________________Who do you live with?_________________________
How do you learn best? □ Read it □ Tell me □ Show me How much education have you completed? ________
Are you:
□ sexually active If so, □ 1 partner □ multiple partners □ with women □ with men
□ A parent If so, how many children? _____________________
FAMILY HISTORY: Has anyone in your family had any of the following? (Check appropriate box)
Mother
Father
Maternal
Paternal
Brothers/
Other
Grandparent
Grandparent
Sisters
High Blood Pressures/
Hypertension
Heart Attack/
Heart Surgery
Diabetes
Stroke
Cancer
(Type/Location)
Osteoporosis
Thyroid Problems
Mental Illness
Glaucoma
Please check any of the following problems that apply to you:
____ no problems
General
Genitourinary
Skin
Endocrine System
Allergy
Eyes
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fever
urinary frequency
rash
excessive urination
seasonal symptoms
blurred vision
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sweats
burning with urination
changing mole
excessive thirst
sneezing
changing vision
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Respiratory
blood in urine
itching
fatigue
itchy eyes
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cough
problems urinating
slow healing
heat intolerance
runny nose
GI System
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shortness of
awaken at night to
wounds
cold intolerance
nasal congestion
nausea
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breath
urinate
Cardiovascular
Neurologic System
post nasal drip
vomiting
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wheezing
problems with sex
chest pain or
numbness
Hematologic System
constipation
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shortness of
exposure to sexually
pressure
tingling
easy bruising
abdominal pain
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breath with
transmitted disease
ankle swelling
headaches
easy bleeding
diarrhea
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exertion
Mental Health
palpitations
weakness
hard to stop
blood in stool
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insomnia
bleeding
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Ear/Nose/Throat
guilt
Daily Living
Musculoskeletal
Nutrition
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ear pain
depression
violence in your home
joint swelling
On a special diet
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runny nose
anxiety
changes in functional ability
joint pains
weight gain or
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sneezing
suicidal thoughts
changes in eating habits
muscle pains
loss greater than
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post nasal drip
changes in sleeping habits
10 pounds
swelling
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