Medical History Form Page 2
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1
2Marital Status: (circle) Married Single Widowed
Have you ever smoked? (circle)
Yes
No
Number of children? _____________________
If yes, how long have you smoked? ____________
If yes, how long ago did you quit?
___________
How many caffeine drinks do you consume daily?
Do you drink alcohol? Yes
No longer
Never
1 2 3 4+
If yes, do you drink:
Daily Weekly Social
Review of Body Systems
Please identify if you currently have problems related to the following systems:
Constitutional Symptoms:
Hematologic/Lymphatic Symptoms:
Fever
Yes
No
Swollen Glands
Yes
No
Chills
Yes
No
Blood Clotting Problems Yes
No
Gastrointestinal Symptoms:
Genitourinary Symptoms:
Abdominal Pain
Yes
No
Urine Retention
Yes
No
Nausea/Vomiting
Yes
No
Painful Urination
Yes
No
Indigestion
Yes
No
Visible Blood in Urine
Yes
No
Urinary Frequency
Yes
No
Urinary Leakage
Yes
No
Cardiovascular Symptoms:
Neurological Symptoms:
Chest Pain
Yes
No
Tremors
Yes
No
Hypertension
Yes
No
Difficulty Walking
Yes
No
Heart Attack
Yes
No
History of Seizure Disorder Yes No
High Cholesterol
Yes
No
Pacemaker or Valve
Yes
No
Musculoskeletal Symptoms:
Joint Pain
Yes
No
Integumentary Symptoms:
Neck Pain
Yes
No
Skin Rash
Yes
No
Back Pain
Yes
No
Persistent Itch
Yes
No
Boils
Yes
No
Psychologic:
Do you have Anxiety? Yes
No
Endocrine Symptoms:
Are you depressed?
Yes
No
Unexplained Weight Loss Yes No
Excessive Thirst
Yes No
Hot/Cold Spells
Yes No
Number of Pregnancies __________________
Number of Vaginal Deliveries ______________
Respiratory Symptoms:
Do you use Estrogen/Hormone Replacement? Yes No
Wheezing
Yes No
Frequent Cough
Yes No
Current PSA if known: ____________ (Males Only)
Shortness of Breath
Yes No
Date drawn ______/________/_______
Lab/Physician where sample was drawn
_________________________________
Is there any additional information that you feel your physician should know?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Today’s date ____/______/________
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