Medical History With Surgical History & Medications
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1Medical History
Surgical History
Have you ever had any of the following:
________________________
Cancer? Where______
________________________
o
Last treatment? _____
Radiation
________________________
Chemotherapy
________________________
HIV/AIDS
Hepatitis (A, B, C)
________________________
Diabetes (Insulin / No Insulin)
________________________
Asthma
COPD/Emphysema/Chronic Bronchitis
________________________
Tuberculosis
________________________
Are you Pregnant? Yes or No
Females under 50 LMP____
________________________
Blood clot (arm / legs / lungs / brain)
Bleeding Problems
Hemophilia
Sickle Cell Anemia
Osteoporosis
Pain Medications
Stomach Ulcer (still suffering / treated)
Drug name, strength, dose, how often
High Blood Pressure (treated / medication / diet)
________________________
Heart Disease
Thyroid Problem
________________________
Depression, (if yes any suicidal attempts) (yes or no)
________________________
Other: __________
_______________
________________________
_______________
________________________
Family History
________________________
Has your immediate family had the following:
________________________
Cancer
________________________
Rheumatoid Arthritis
Back Problems
________________________
Diabetes
Bleeding Problems
Heart Disease
High Blood Pressure
Stroke
Depression
Other Medications
Other: ____________
Names only
_________________
________________________
_________________
________________________
Social History (Must Answer Yes or No)
________________________
Are you? (Student / Single / Married / Separated/ Divorced / Widowed)
________________________
Exercise Regularly? (Yes or No)
________________________
Do you need assistance with? (Walking / Driving / Cooking / Cleaning)
Do you drink alcohol? (Yes or No)
________________________
If yes, how many drinks a day? ___________
________________________
If yes, for how many years? ______________
Do you smoke? (Yes or No)
_
If yes, many pack a day? ________________
If yes, for how many years? _______________
Have you ever been addicted to drugs? (Yes or No)
If yes when did you use them last? __________ What Drug/s? __________________
___________________
___________________
Allergies________________________________________________________________
Clinical use only:
Height____
Weight____
BP____
P____
Temp____
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Parent category: Medical