Patient Medical History Form Page 2

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MEDICATIONS:
List all medications, or drugs you currently use or have used at home within the last three months. Include those with a prescription from a doctor,
those you bought over the counter in a store, any you received from a friend, any vitamins, home remedies, laxatives or any other product you take to
improve your health. If you do not know all this information, please bring all the bottles or boxes with you to your next office visit. (Please attach an
additional page if you need more space).
Name & Strength of Medication
Amount taken
Approximate date started
1.
_____________________________________________________________________________________________
2.
_____________________________________________________________________________________________
3.
_____________________________________________________________________________________________
4.
_____________________________________________________________________________________________
5.
_____________________________________________________________________________________________
6.
_____________________________________________________________________________________________
7. ______________________________________________________________________________________________
Medication Allergies:
List anything medications you are allergic to:
Item
Describe reaction you had
1.
________________________________________________________________________________________________
________________________________________________________________________________________________
2.
________________________________________________________________________________________________
________________________________________________________________________________________________
3.
________________________________________________________________________________________________
________________________________________________________________________________________________
4.
________________________________________________________________________________________________
________________________________________________________________________________________________
FOR WOMEN ONLY
1. Approximately how old were you when you started having menstrual periods? ______________
2. Which statement describes you?
□
I am still having regular periods.
□
My periods are irregular.
□
I am pregnant.
□
My periods have stopped on their own (menopause). Age___________
□
I have had an operation which stopped my periods.
□
□
One ovary only
Uterus only
□
□
Both ovaries
Uterus and one ovary
□
□
Other
Uterus and both ovaries
3. Number of pregnancies ____________________
Number of children born alive______________
Number of miscarriages___________________
4. Are you or have you ever been on hormone replacement (estrogen/progesterone)? Please explain_______________________________________
P: CCC Forms/Front Office/New Patient Forms
Revised 6/18/2014
2

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