Wells Institute
Medical History

Patient Initials______

Wells Institute Family Practice

Patient Name______Social Security #______

Address______Birth date______

City/State/Zip______Sex______

______Race______

Home Phone______Ethnicity Hispanic/Latino

Work Phone ______ Not Hispanic/Latino

Cell Phone ______

Email Address ______

Emergency Contact

Phone Number of Contact

Relationship ______Zip Code ______

* I have completed this medical history form to the best of my knowledge and as completely and accurately as possible. I give Wells Institute for Health Awareness permission to collect and review my medical history.

Patient Signature ______Date Completed______

STAFF ONLY:

* Reviewed by Wells Institute staff:

Signature ______Date ______

* Reviewed by Physician: Letitia Thompson-Hargrave, DO / Kathryn Harkenrider, FNP-C

Signature ______Date ______

Initial Medical History Questionnaire

Sex

Male Female / Weight: ______lbs Height: ______ft. ______in.

Date of Birth

/ Ethnicity (Race)

Personal Information

Occupation

/ Patient is currently:
Working Retired Other ______

Alcohol Consumption

oz / Day ______Never Social Daily Binge
Drinks / Week ______/ Alcoholic Beverage Preference
Smoking / Never
Quit /

Year When Quit

/ Current Tobacco Use /

Type & Amount

/

Years Used

Exercise: Type of Exercise:
Frequency Per Week: / Exposure to Second Hand Smoke:
Yes No
Drug Allergies (List All and Date Discovered):
Other Allergies
pollen/grasses/mold poison ivy/oak insect stings dust/dust mites
Food (Specify): ______

Has patient participated in any research study within the last 6 months? Yes No

If yes, for what medical condition? ______

Completion Date ______Where? ______

Endocrine and Metabolic Problems : / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
Diabetes
Type 1 Type 2
Controlled By:
Diet Oral Med Insulin
Diabetic Neuropathy
Diabetic Retinopathy
Thyroid Disease
Gout
Cardiovascular Problems: / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
High Blood Pressure
High Cholesterol
High Triglycerides
Heart Attack
Angina or Chest Pains
Triggered By Physical Effort
Experienced For Last 2 Months
Palpitations
Heart Murmur
Heart Catheterization (Angiogram) / When?
______ / Results
______
Angioplasty / When?
______ / Results
______
Echocardiogram / When?
______ / Results
______
Family history of heart disease / Who?
______
Bypass Operation / When?
______ / Results
______
Stent Insertion / When?
______ / Results
______
Aneurysm
Varicose Veins or Blood Clots
Coronary Artery Disease
Congestive Heart Failure
Respiratory (Lung) Problems: / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
Asthma – Adult or Childhood
COPD/Emphysema/Chronic Bronchitis
Pneumonia
Tuberculosis or Exposure to TB
Chronic Cough
Gastrointestinal Problems (Stomach and Digestive): / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
Heartburn
GERD
Liver or Gallbladder Disease
Irritable Bowel Syndrome (IBS) / Sub Type:
Colitis
Hepatitis A, B, C or Other
Surgery: Gastric Bypass, Lap Band, Other______ / Type:
Neurologic (Nerve) Problems: / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
Tremors
Seizures or Convulsions
Stroke
Migraines
Headaches
Depression
Anxiety
Neuropathy
Fibromyalgia
Shingles
PHN
Restless Leg Syndrome
ADHD/ADD
Dermatologic (Skin) and
Hematologic (Blood) Problems: / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
Anemia
HIV Positive
Psoriasis
Recurrent Eczema or Rashes,
Hives or Skin Cancer / Type:
Eye, Ear, Nose or
Throat Problems: / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
Glaucoma
Cataracts
Macular Degeneration
Hearing Loss
Otitis Externa (Swimmer’s Ear)
Seasonal Allergies
Genitourinary Problems: / No / Yes / Active / Date of Diagnosis
Start - Stop
Frequent, Painful or
Nighttime Urination
Stress Urinary Incontinence
Urgency Incontinence
Over-Active Bladder
Frequent Urinary Tract Infections
Bladder Cancer
Kidney Disease
Women: Menopause / Date of: Last Menstrual Period ______
Last PAP Smear ______
Women: Hysterectomy / When? ______
Women: Tubal Ligation
Women: Birth Control
Method: ______ / Type:
Women: Mammogram / Date of last Mammogram: ______
Women: Breast Lumps or Cancer
Women: Sexual Dysfunction
Women: Osteoporosis
Men: Enlarged Prostate
Men: Erectile Dysfunction
Joint and Muscle Problems: / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
Arthritis
Rheumatoid Osteo
Osteoporosis
Fractures or Breaks
Location:______
Sleep Disorders: / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
Insomnia
Sleep Apnea
Other: / No / Yes / Active / Inactive / Date of Diagnosis
Start - Stop
Obesity (BMI over 30)
Cancer
Type: ______Therapy: ______

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Wells Institute
Medical History

Patient Initials______

Mother / Father / Children
Son Daughter / Siblings
Brother Sister / Mothers Parents
Grandfather Grandmother / Fathers Parents
Grandfather Grandmother
Alcoholism / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Asthma / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Bleeding Disorder / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Cancer / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Diabetes / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Epilepsy/Convulsions / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Glaucoma / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Hair Loss / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Heart Disease / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
High Blood Pressure / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Kidney Disease / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Mental Illness / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Migraine / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Osteoporosis / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Stroke / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
Thyroid Disease / □ / □ / □ / □ / □ / □ / □ / □ / □ / □
□Alive
□Deceased / □Alive
□Deceased / □Alive
□Deceased / □Alive
□Deceased / □Alive
□Deceased / □Alive
□Deceased / □Alive
□Deceased / □Alive
□Deceased / □Alive
□Deceased / □Alive
□Deceased

Family History Form

Page 1 of 8Revised 04/12/2017

Wells Institute
Medical History

Patient Initials______

Current Medication (Frequency within 60 Days)

Name of Medication / Dosage / Start Date / What are you taking the medication for? / Frequency / Comments
1.
2.
3.
4.
5.
6.
7.
8.
Please List All Previous Operations and Hospitalizations (If more than 5, continue on the back)
Reason For Operation or Hospital Stay / Date / Comments
1.
2.
3.
4.
5.

Page 1 of 8Revised 04/12/2017