Medical History Form
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1Medical History Form
Name
Birth Date
Gender:
M
F
Occupation
Height
Weight
Handedness:
R
L
Primary / Referring MD
Pharmacy & city
What are your hobbies / sports played
Reason for visit
Date of onset
Is this:
Work Related
Car accident
Sports injury
Other
Previously evaluated or treated. How?
Medical History
Have you recently experienced any of these symptoms:
No medical history
No recent symptoms
High blood pressure
Hematologic
General
Heart attack
Oncologic
Fever
Coronary Artery Disease
Chills
Bleeding tendency
High cholesterol
Weight Gain/Loss
Easy bruising
COPD
Rash
Head and Neck
Asthma
Cardiovascular
Osteoarthritis
Headaches
Chest Pain
Nosebleeds
Lyme Disease
Palpitations
Sore throat
Rheumatoid
Gout
Respiratory
Urinary/Gyn
Lupus
Short of breath
Blood in urine
Thyroid disease
Cough
Loss of bladder
Diabetes
Musculoskeletal
control
Reflux (GERD)
Neck Pain
Are you pregnant
Ulcers
Back Pain
Blood clot (DVT/PE)
Social Do you:
Joint Pain
Cancer(type)
Muscle Pain
Smoke Cig. (
packs / day)
Depression
Quit smoking (
/
/
)
Gastrointestinal
Anxiety
Stroke
Abdominal pain
Drinks / week)
Drink Alcohol (
Renal failure
Endocrine
Quit drinking (
/
/
)
Sleep apnea
Excessive thirst
Have a history of substance abuse
Osteoporosis
Use or have used smokeless tob.
Other
Medications (dose / frequency)
none
Surgeries (procedure / Year)
none
Family History (disease / relationship)
none
Allergies (medication / reaction)
none
Patient/Guardian Signature
Patient/Guardian Signature
Date
Date
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Parent category: Medical