Health History

HEALTH HISTORY

Name______Date______Age______

Referring Doctor______Date of last exam______

Preferred Pharmacy and Phone #______

Reason for visit______

PERSONAL MEDICAL HISTORY

Have you been diagnosed with any of the following: give a brief explanation and approximate date

___Blood Clots______Breast Problems______

___Diabetes______Heart Disease______

___High Blood Pressure ______Lung Problems______

___High Cholesterol______Kidney Disease______

___Cancer______Thyroid Problems______

___Anemia______Asthma______

___Hernia______Chest Pain______

___Abdominal Pain______Recurring Diarrhea______

___Acid Reflux______Recurring Constipation______

___Abnormal Pap______Weight Loss______

___Other______

PAST SURGICAL HISTORY

List all surgeries and give approximate date

______

MEDICATIONS

Please list all medications you are currently taking including over the counter medication such as Tylenol

______

ALLERGIES

Drugs, Foods, and Environmental

______

FAMILY MEDICAL HISTORY

Has anyone in your family had the following (circle yes and indicate relationship: father, maternal , etc.)

Ovarian Cancer Yes Relationship______

Uterine Cancer Yes Relationship______

Breast Cancer Yes Relationship______

Colon Cancer Yes Relationship______

Heart Disease or Stroke Yes Relationship______

Osteoporosis Yes Relationship______

Kidney Disease Yes Relationship______

Asthma Yes Relationship______

Hypertension Yes Relationship______

Other (please specify) Yes Relationship______

WOMEN’S HEALTH

Date of last mammogram______

Date of last menstrual period______

Date of last pap smear ______

Do you have a history of abnormal paps? ______

Are you now, or could you be pregnant?______

Current method of birth control______

Length of cycles______

Age of menarche______

Total number of times you’ve been pregnant ______

Number of living children____ Abortions____ Miscarriages____ Ectopic (tubal)____

PAST DIAGNOSTIC TESTING

Please give approximate date

Colonoscopy ______

Bone Density______

Ultrasound ______

Stress Test______

CT Scan ______

X-Ray ______

SOCIAL HISTORY

Smoking History: Current ______Former ______Never ______

Are you exposed to second hand smoke? ______

Do you drink coffee or tea? ______

Do you drink alcohol? ______If yes, how often? ______

Do you now or have you ever taken illegal drugs? ______

What is your occupation? ______

Are you: _____Married _____Single _____ Divorced _____ Widowed

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. I WILL NOT HOLD MY DOCTOR OR ANY MEMBER OF HIS/HER STAFF RESPONSIBLE FOR ANY ERRORS OR OMISSIONS I MAY HAVE MADE IN THE COMPLETION OF THIS FORM.

SIGNED______DATE______