Patient Medical and Family History

Patient Medical and Family History

Patient Name (last, first MI): ______Today’s Date:______

Date of Birth:______Account #______

Are you allergic to any medication? YES or NO

If YES, please list: ______

______

Please List All Medications That You Are Currently Taking:
Name: ______Strength:______How Often:______
Name: ______Strength:______How Often:______
Name: ______Strength:______How Often:______
Name: ______Strength:______How Often:______
Name: ______Strength:______How Often:______
Name: ______Strength:______How Often:______
Name: ______Strength:______How Often:______
Please List All Previous Surgical Procedures:
Type: ______Year: ______Type: ______Year: ______
Type: ______Year: ______Type: ______Year: ______
Type: ______Year: ______Type: ______Year: ______
Have You Ever Had The Following:
Diabetes Yes No Controlled by: Diet Pills Insulin
High Cholesterol Yes No Count & When: ______
Stress Test Yes No When & Where: ______
Nuclear Stress Test Yes No When & Where: ______
Cardiac Catheterization Yes No When & Where: ______
PTCA (Angioplasty) Yes No When & Where: ______
Cardiac Bypass Surgery Yes No When & Where: ______
Pacemaker Yes No When & Where: ______
Heart Valve Replacement Yes No When & Where: ______
Defibrillator Implant Yes No When & Where: ______
Anemia Yes No Hiatal Hernia Yes No
Gout Yes No Arthritis Yes No
Stroke Yes No Gallbladder Problems Yes No
Breathing Difficulties Yes No Thyroid Problems Yes No
Palpitations Yes No Kidney Problems Yes No
Heart Murmur Yes No Ulcers Yes No
Abnormal ECG Yes No Bowel Problems Yes No
Rheumatic Fever Yes No Psychiatric Problems Yes No
High Blood Pressure Yes No Liver Problems Yes No
Angina Yes No Heart Attack Yes No
Overweight Yes No Other Yes No
______
Do you currently use Tobacco? Yes No
If Yes, circle which: Cigars Cigarettes Pipe Chewing Tobacco Vape
How many years? ______How much per day? ______
Do you currently use Alcohol? Yes No
If Yes, frequency: Daily Weekly Social
Family History
Father Living: Yes No Age or Age at Death: ______Cause of Death: ______
Mother Living: Yes No Age or Age at Death: ______Cause of Death: ______
How many Brothers: ______# Living______# Deceased______
Age and Cause of Death:______
How many Sisters: ______# Living______# Deceased______
Age and Cause of Death:______
How many Children: ______Ages: ______
Any Health Problems? ______
If Yes, of what nature: ______
Do any of the following illnesses run in your family?
Diabetes: Yes No Which Member: ______
Stroke: Yes No Which Member: ______
Hypertension: Yes No Which Member: ______
Heart Disease: Yes No Which Member: ______
Is there anything else we should know regarding your health or historical background?
Print Name:______Date of Birth:______