First Choice Urgent Care Medical History Form
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1First Choice Urgent Care
Medical History Form
Today’s Date: ____________
Patient Name: ________________________________________ Date of Birth: __________________________
Current/Past Medical History
Allergies
Current Medications
____________________________________
1.________________________ for ___________________
____________________________________
2.________________________ for ___________________
____________________________________
3.________________________ for ___________________
____________________________________
4.________________________ for ___________________
Health History: Have you ever had OR Do you currently have:
Yes
No
Yes No
Asthma/Chronic Lung Disease/Emphysema
Head or Spinal Injury
Tuberculosis
Broken Bones
Heart Disease/Angina/Heart Attacks
Thyroid Problems
High Blood Pressure
Diabetes
Blood Clots
Liver/Gall Bladder Disease
Anemia/Bleeding Disorders/Sickle Cell
Colon Disorders
Strokes
Acid Reflux/Ulcers
Seizures/Fits/Fainting
Kidney Problems/Stones
Vision/Hearing Disorders
Sexually Transmitted Diseases
Any Other Nervous System/Muscle Disease
Mental Illness/Depression
Cancer
Permanent Defect from Illness
Arthritis
Any other Disorders
Please explain any positive responses: __________________________________________________________
Any past Surgeries/Procedures (colonoscopy, cardiac caths, stress tests, etc.)? Yes No
If yes, please list and give approximate date(s):
1. ____________________________ 4.________________________ 7. __________________________
2. ____________________________ 5.________________________ 8. __________________________
3. ____________________________ 6.________________________ 9. __________________________
Immunizations Up-to-Date? Yes No Last Tetanus Shot _____________ Exercise Pattern __________
Women Only: Last Pap _____________ Last MMG _______________ Men Only: Last PSA ____________
Social History
Do you use tobacco products? Yes No
Do you use illegal Drugs? Yes No
#PPD ________ Smokeless _________
Describe: _______________________________________
Do you drink alcohol? Yes No Are there environmental risks involved in your job? Yes No
# of drinks/month ______________
if yes, Describe: ______________________________________
Family History
Do you have a family history of:
Heart Disease? Yes No
Diabetes? Yes No
High Blood Pressure? Yes No
Cancer? Yes No
Stroke? Yes No
Bleeding Disorders? Yes No
Please explain positive response(s): _____________________________________________________________
Patient Signature ________________________________ Physician Signature __________________________
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