Patient Personal History Template
ADVERTISEMENT
1THE CENTERS FOR OCCUPATIONAL HEALTH (COH)
PATIENT PERSONAL HISTORY
Note to patient: The examining Medical Provider requests that you complete this brief history. This form and information is
CONFIDENTIAL and will become a part of your medical record.
Patient Name: __________________________________________________________DOB:____________________
MEDICATIONS: (include over the counter medications)
ALLERGIES: NO
YES
If yes, please list:
_________________________________________________________________________________________________
HOSPITALIZATIONS/ SURGERIES:
Date: _____________________Reason:_______________________________________________________________
Date: _____________________Reason: _______________________________________________________________
Date: _____________________Reason: _______________________________________________________________
PERSONAL HISTORY/REVIEW OF SYSTEMS:
Have you experienced any of the following? Please circle and explain.
Aids or HIV Positive
Cancer
Headaches/Neurological
Psychlogical Problems
Problems/ Stroke
Alcoholism Drug Abuse
Diabetes
Heart Disease/Murmur
Sexually Transmitted Disease
Anemia
Elevated Cholesterol
Hernia
Skin Condition
Anxiety/Depression
Epilepsy
High Blood Pressure
Tuberculosis (TB)/ Pulmonary
Disease
Arthritis/Back Pain/Injury
Fractures/Bone Disease
Kidney Disease
Other
Blood Disorder/Bleeding
Gastrointestinal Disease
Liver Disease/Hepatitis
Explain all circled items:_______________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
FAMILY HISTORY: Does a family member suffer from any of the conditions above? Explain below
Mother: Yes No
Brother: Yes No
Sister: Yes No
Father: Yes No
Child(ren) Yes
______________________________________________________________________________________________
______________________________________________________________________________________________
SOCIAL HISTORY:
Yes No
Do you smoke?
How Much? _____________________________
Yes No
Have you smoked in the past?
How Long? ______________________________
Yes No
Do you use other tobacco products?
Name Products? __________________________
Yes No
Do you drink alcohol?
How much?______________________________
Yes No
Do you take any illegal drugs?
Please Name: _____________________________
The above answers are true and accurate. I realize that any untrue answers may affect my evaluation and
treatment, the Examiner’s recommendations, and validity of this examination.
PATIENT SIGNATURE: _______________________________________________ Date: _____________________
____________________________________DO NOT WRITE BELOW THIS LINE ________________________
Medical Provider’s Comments: ____________________________________________________________________
_______________________________________________________________________________________________________________________
Medical Provider’s Signature: _________________________________________ Date: _______________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical