Patient History

ADVERTISEMENT

Corridor Primary Care, P.A.
512-396-1000
Patient History
Name (Please print): ______________________________ Age: _______ Date of Birth: _____________
I.
SOCIAL HISTORY
A. Marital Status: (Check one)
Single
Married: How long? _______
Widowed: When? ________
Divorced: When? ________
B. Children: (If any)
Name
Age
Residence (City/State)
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
_____________________
______
___________________________
C. Occupation: __________________________ Are you disabled? Yes ___ No ___
D. Education: (Last grade attended) _______________________________
E.
Religious preference: _______________________________________
F.
Hobbies/ Interests: _________________________________________
II.
HABITS
A. Smoking:
Never Smoked
Current Smoker Number of packs per day: ______ Number of years smoked: _____
Former Smoker Age you quit: _______
Number of years smoked: _____
B. Alcohol Use:
How much per week? ___________________
For how long? _________________
C. Other drugs: (Street drugs) _______________________________________________
D. Exercise:
Do you exercise routinely? Yes ____ No ____
What type of exercise? __________________________________________________
III.
MEDICAL HISTORY
A. Medication Allergies _____________________________________________________
B. Surgical History (Please list all operations and approximate date of each)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
C. Injuries (Please list all serious INJURIES, CONCUSSIONS OR FRACTURES)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
-Continued on other side-

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Patient History Patient History Medical
Patient History Form/history Of Present Illness/past Medical, Family & Social History Patient History Form/history Of Present Illness/past Medical, Family & Social History Education
Patient History Form/history Of Present Illness/past Medical & Social History Patient History Form/history Of Present Illness/past Medical & Social History Education
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History And Physical Form Patient History And Physical Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Business
Patient History Information Form Patient History Information Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 2