Patient Intake: Medical History (Page 2 of 4) in pdf

Is there a family history of anything NOT listed here? ( ) N ( ) Y (Please explain) _______________________

___________________________________________________________________________________________

MD NOTES: _______________________________________________________________________________

___________________________________________________________________________________________

Have you ever had surgery or been hospitalized? ( ) N ( ) Y (Please describe) _________________________

___________________________________________________________________________________________

MD NOTES: _______________________________________________________________________________

___________________________________________________________________________________________

Childhood Illnesses

Measles

( ) N

( ) Y

Mumps

( ) N

( ) Y

Chicken Pox

( ) N

( ) Y

Have you or a family member ever been diagnosed with a psychiatric or mental illness? ( ) N ( ) Y (Please

describe) ___________________________________________________________________________________

Have you ever taken or been prescribed antidepressants? ( ) N ( ) Y For what reason ___________________

Medication(s) and dates of use: ______________________________ Why stopped: _______________________

Please list all current prescription medications and how often you take them (example: Dilantin 3x/day).

DO NOT include medications you may be currently misusing (that information is needed later): ______________

___________________________________________________________________________________________

Please list all current herbal medicines, vitamin supplements, etc, and how often you take them: ____________

___________________________________________________________________________________________

MD NOTES: _______________________________________________________________________________

___________________________________________________________________________________________

Please list any allergies you have (eg, penicillin, bees, or peanuts): _____________________________________

___________________________________________________________________________________________

MD NOTES: _________________________________________________________________________ ______

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Patient Intake: Medical History Page 2