Medical History Form Page 2
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2MEDICAL HISTORY
Birthdate____/____/____
Age________
NAME:_____________________________________________
PLEASE LIST ANY SURGERY YOU HAVE HAD:
FAMILY HISTORY:
1. Do any blood relatives have a problem/diagnosis similar to your current problem?
q Yes
q No
2. Have any of your blood relatives ever had any of the following?
q Stroke
q Epilepsy
q Migraine
q Alzheimer's disease
q Parkinson's disease
q Multiple Sclerosis
q Neuropathy
3. List any other medical conditions that your parents, siblings or children have or have had:
SOCIAL HISTORY:
q Never smoked
q Quit Smoking: When did you quit?______________
SMOKING:
q Currently smoking
How much?_______________________________
q Never
q Socially
q 1/day
q More than 2/day
q in recovery
ALCOHOL USE:
q Never
q Sometimes
q Frequent
q What type? _________________
RECREATIONAL DRUG USE:
q Yes
q No
Have you ever injected drugs?
q Retired q Disabled
q Work outside the home
Occupation _________________________
WORK STATUS:
q Single
q Married
q Divorced
q Living with significant other
q Widowed
MARITAL STATUS:
q Yes
q No
DO YOU CURRENTLY DRIVE?
q Yes
q No
DO YOU HAVE AN ACTIVE DRIVERS LICENSE?
q
q
q
WHAT IS YOUR HIGHEST LEVEL OF EDUCATION?
High School
College
Graduate School
REVIEW OF SYSTEMS: Please check any of the following symptoms you have had recently:
q
q
q
Persistent Fever
Joint Pain
Ringing in Ears
q
q
q
Unexplained Weight Loss
Rash
Persistent Dizziness
q
q
q
Fatigue
Easy Bruising
Difficulty Speaking
q
q
q
Chest Pain
Blood Clots in Legs or Lungs
Difficulty Swallowing
q
q
q
Palpitations
Abnormal Bleeding
Weakness in Arms or Legs
q
q
q
Difficulty Breathing
Trouble Sleeping
Numbness
q
q
q
Nausea
Headache
Tingling
q
q
q
Vomiting
Neck Pain
Loss of Balance
q
q
q
Diarrhea
Back Pain
Difficulty Walking
q
q
q
Discolored Urine
Blindness
Confusion
q
q
q
Urinary Incontinence
Blurry Vision
Memory Loss
q
q
q
Bowel Incontinence
Double Vision
Impotence
q
q
q
Muscle Pain
Hearing Loss
Tremor
DATE OF LAST MENSTRUAL PERIOD:
Revised 4/3/13
Page 2 of 2
Reviewed with Patient by:_________
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