MEDICAL HISTORY FORM

Name: ______Today’s Date: ______

SS#:______Date of Birth: ______

Family Physician Name & Telephone#:______

Pharmacy Name, City, & Telephone #: ______

What part of the body are you being seen for today? Rt Lt ______

Current Problem is the result of a:

 Car Accident ÿ Work Accident ÿ Other ______Date of Injury: ______
Medication Dose Reason for Medication Side Effects

Do you have any allergies to any medications? ÿ Yes ÿ No

If yes, list and describe all that apply______

Do you have an allergy to Latex? ÿ Yes ÿ No

Do you have an allergy to contrast dye or iodine? ÿ Yes ÿ No

Are all immunizations up to date: ÿ Yes ÿ No If no, which immunizations are due? ______

Are you Pregnant? ÿ Yes ÿ No Are you Nursing? ÿ Yes ÿ No

Review of Systems ÿ None

Are you currently having or have you had problems with your:

Describe if not listed Describe if not listed

Eyes ÿ______Hematic, Blood ÿ ______

ÿ Blurred vision ÿ Easy bleeding

ÿ Double vision ÿ Easy bruising

ÿ Vision loss ÿ Anemia

Ears, Nose, Throat ÿ ______Cardiovascular ÿ ______

ÿ Hearing loss ÿ Chest pain

ÿ Hoarseness ÿ Palpitations

ÿTrouble swallowing Neurologic ÿ ______

Respiratory, Lungs ÿ ______ÿ Headaches

ÿ Chronic cough ÿ Dizziness

ÿ Shortness of breath ÿ Seizures

Digestion ÿ ______ÿ Balance problems

ÿ Heartburn, ulcers ÿ Numbness/tingling

ÿ Nausea, Vomiting Psychologic ÿ ______

ÿ Blood in stool ÿ Depression

Urinary ÿ ______ÿ Drug/Alcohol addiction

ÿ Painful urination ÿ Sleep disorder

ÿ Blood in urine Skin ÿ ______

ÿ Kidney problems ÿ Frequent rashes

Lymphatic ÿ ______ÿ Skin ulcers

ÿ Leg swelling ÿ Lumps

Endocrine ÿ ______Vascular ÿ ______

ÿ Heat or cold intolerance ÿ Claudication

Weight ÿ ______

ÿ Weight loss

ÿ Loss of appetite

Name: ______Date of Birth: ______

Past Medical History ÿ None

ÿ Asthma ÿ Anemia ÿHigh Blood Pressure

ÿ Stroke ÿ Diabetes ÿ Heart Murmur

ÿ Irregular heartbeat ÿ Heart Attack/CAD ÿ Pneumonia

ÿ Emphysema ÿ Pulmonary Emboli/Blood clot ÿ Hepatitis

ÿ GERD/Reflux ÿ Liver Disease ÿ Rheumatoid Arthritis

ÿ Degenerative Arthritis ÿ Osteoporosis ÿ Gout

ÿ Kidney problems ÿ Prostate problems ÿ Multiple Sclerosis

ÿ Skin rashes/Psoriasis ÿ HIV/AIDS ÿ Other ______

ÿ Cancer, specify type and treatment ______

Past Surgical History

Surgeries/Hospitalizations Year Complications

Have you ever had general anesthesia? ÿ No ÿ Yes

Have any problems with anesthesia? ÿ No ÿ Yes, describe: ______

Family History

Member Alive Deceased Age Health Status or Cause of Death
Grandmother (mom’s) A D
Grandfather (mom’s) A D
Grandmother (dad’s) A D
Grandfathers (dad’s) A D
Father A D
Mother A D
Sister/Brother A D
Sister/Brother A D
Sister/Brother A D

Do your parents, siblings, or grandparents have any of the following? Please check all that apply

ÿ Bleeding disorders ÿ Diabetes ÿ Heart disease ÿ Stroke

ÿ High blood pressure ÿ Rheumatoid Arthritis ÿ Osteoporosis ÿ Problems with anesthesia

ÿ Cancer, specify type ______ÿ Genetic disorder, specify type ______

Social History

 Employed  Unemployed  Retired  Disabled  Student

Single  Married  Divorced  Separated  Widowed

Children?  No  Yes #______

Do you live alone? No  Yes

Exercise?  Daily  Weekly  Monthly  Rarely Never

What type of exercise? ______

History of substance abuse?  No  Yes What? ______

Smoke currently?  No Yes _____packs per day for ______years ÿ Never smoked

Quit Smoking?  This year  >1 year  >5 years  >10 years

Previously smoked ______packs per day for ______years

Drink alcohol ÿ how many drinks per week ______ daily  l-2x/week  1-2x/month  1-2x/year

Patient Signature: ______Date:______

Reviewed By: ______Date: ______Pg. 1