New Patient Health History Form Page 2
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7Medicine In Balance
New Patient Health History Form
Medical History (Continued)
Please list allergies to Medications (including the reaction): _____________________________________________
_____________________________________________________________________________________________
Please list any surgeries you have had and when: _____________________________________________________
_____________________________________________________________________________________________
Family History
: Plea se indicate which i m med iate famil y me mbe rs (grandparents, parents, siblings,
and/or children) have ha d any o ne of the follo win g he alth issue s (Specify G, P , S and/or C):
Cancer
Other Fa mily Health
Hist ory
Breast
High Blood Pressure
Mental Illness
Ovarian
Heart Attack
Obesity
Cervical
Stroke
Other
Uterine
Diabetes
Colon
Osteoporosis
Other
Alzheimer’s
Social History
Marital Status:
Married [ ]
Single [ ]
Coupled [ ]
Divorced [ ]
Widowed [ ]
Sexual Orientation: Heterosexual [ ] Homosexual [ ] Bisexual [ ]
Are you currently sexually active? Yes [ ] No [ ]
# of sexual partners (lifetime) ________
Have you ever been hit, slapped, kicked, or otherwise physically hurt by someone?
Yes [ ] No [ ]
Within the past 12 months: Yes [ ] No [ ]
Have you ever been forced to have sexual activities you did not want to have?
Yes [ ] No [ ]
Within the past 12 months Yes [ ] No [ ]
Do you wear your seat belt when you drive? Yes [ ] No [ ] Sometimes [ ]
Do you have at least one smoke detector in your home? Yes [ ] No [ ]
What is your occupation? ________________________________________________________________________
Company name and nature of business ______________________________________________________________
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Parent category: Medical