North Shore Lij Medical History Form
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3Medical History Form
DATE:______________ NAME: ___________________________________________________________________________________________________
Last Name
First Name
DATE OF BIRTH: ________________ AGE: ____________________ HEIGHT: _____________________ WEIGHT: _____________________
REASON FOR VISIT:
Are you experiencing pain today?
YES
NO
Please indicate your level of pain: (“0” for no pain, “10” for unbearable pain)
0
1
2
3
4
5
6
7
8
9
10
Please indicate your handedness:
RIGHT HANDED
LEFT HANDED
AMBIDEXTROUS
PERSONAL/FAMILY HEALTH HISTORY
*circle what’s applicable*
n/a Me Mother Father Sibling(s) Children Other Comments
Diabetes
High blood pressure / Low blood
pressure
Stroke / Blood clot in the brain /
Bleeding in the brain
Cancer (indicate location / year)
Hyper-thyroidism / Hypo-thyroidism
Rheumatic fever, heart attack, stent
placement, valve
damage/replacement,
pacemaker,congestive heart failure,
other heart conditions (indicate
type)
Seizure, epilepsy, period of
lightheadedness, dizziness
Tuberculosis (+) PPD
Asthma, respiratory problems
Mental health conditions
(depression, anxiety, etc.)
Hepatitis (indicate type), liver
disease, jaundice
Migraines, headaches
Bleeding problems
Immunological disorders, frequent
infections
Arthritis, artificial limbs / joints
(where)
Last Name _____________________________ 1/3
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Parent category: Medical