Personal Medical History
Patient’s name: ______Birthdate:______
Other Physicians: (attach separate piece of paper if necessary)
1. Name: ______Telephone number:______
Specialty: ______Fax number:______
2. Name: ______Telephone number:______
Specialty: ______Fax number:______
3. Name: ______Telephone number:______
Specialty: ______Fax number:______
4. Name: ______Telephone number:______
Specialty: ______Fax number:______
Social History Nutritional/Exercise Assessment
Tobacco Marital Status Typical Breakfast
o No o Single ______
o Yes ______ppd x______years o Married
o Civil Union Typical Lunch
Stage o Divorced ______
o Precontemplation o Widow(er)
o ContemplatioN Typical Dinner
o Action Children ______
o Consolidation o Boy(s) Age(s) ______
o Relapse o Girl(s) Age(s) ______Usual Snacks/Beverages
______
Type of Exercise:
Illicit Drug Use ______
o No o Yes Advance Directive
o Yes oNo
Types/Quantity/Frequency o No Interval Change
______
Family History — list important medical problems of your parents:
Mother:______
Father:______
Any other special medical information:______
Family History Notes______
Mother Father
o Alive, Age ____ o Alive, Age ____
o Deceased, Age ____ of ______o Deceased, Age ____ of ______
Sister(s) Brother(s)
o Alive, Age ____ o Alive, Age ____
o Deceased, Age ___ of ______o Deceased, Age ____ of ______
o Alive, Age ____ o Alive, Age ____
o Deceased, Age ___ of ______o Deceased, Age ___ of ______
o Others o Others
Drug sensitivity and allergies (describe):______
Have you ever been told you had one of the following?
Lung disorder oyes ono Disease of the kidney oyes ono
High blood pressure oyes ono Diabetes oyes ono
Heart trouble oyes ono Arthritis oyes ono
Nervous disorder oyes ono Hepatitis oyes ono
Disease or disorder of the digestive tract oyes ono Malaria oyes ono
Any form of cancer oyes ono
If answered yes to any of the above, please describe:______
Disease or disorder of the blood? (describe)______
Any physical defect or deformity? (describe)______
Any vision or hearing disorders? (describe)______
Any life-threatening conditions? (describe)______
Have you been treated by a physician or been disabled or hospitalized during the last year? (describe) ______
Have you had or been advised to have a surgical operation within the last five years? (describe) ______
Signature ______Date ______
1
Texas Kidney Institute
www.texaskidneyinstitute.com
Tel: 214 396 4950 Fax: 877 423 5360