Fillable PATIENT MEDICAL HISTORY FAMILY HISTORY MEDICATIONS

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PATIENT MEDICAL HISTORY FAMILY HISTORY MEDICATIONS

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PATIENT MEDICAL HISTORY
Name __________________________________________ Age ______ DOB __________ Date___________
Years of Education (H.S. =12) ______ Handed: Left Right Gender: Male Female
Reason for Visit ____________________________________________________________________________
___________________________________________________________________________________________
Disease No Yes
Alzheimer’s
Headache
Cancer
Epilepsy
Heart Disease
High Blood Pressure
Diabetes
Stroke
Anxiety, Depression, Panic
Attacks or OCD
Problems with Attention or
Learning (i.e. AHDH)
Obesity
Other
MEDICATIONS
FAMILY HISTORY
(Relatives, Excluding Self)
Medication: Dose
Drug / Allergies
1. ___________________________
2. ___________________________
3. ___________________________
4. ___________________________
Do you smoke? Yes No
How much? ________________________
Do you drink Alcohol? Yes No
How much? ________________________
For Women Only
Menstrual Periods
Regular irregular none
Last Menses _________________________
Are you taking birth control pills?
Yes No
Is there a possibility you might be pregnant?
Yes No
Are you trying to get pregnant?
Yes No
Please Fill Out Page 2
© 2008 All Rights Reserved
Please circle below if you have had any of these symptoms/problems
Constitutional: fever / chills / significant weight loss or weight gain
Eyes: visual difficulties / double vision
Ears, Nose, Mouth, Throat: difficulty hearing / swallowing issues / sore throat / dizziness
Cardiovascular: chest pain / shortness of breath / high blood pressure / heart attack
Respiratory: any pulmonary issues / wheezing
Gastrointestinal: nausea / vomiting / diarrhea / blood in stool
Genitourinary: urinary difficulties / blood in urine
Musculoskeletal: recent injury / significant joint pain
Skin: rash / bruising
Neurologic: history of stroke / seizure / numbness / weakness / headache / neck pain / back pain
Psychiatric: sadness / depression / significant anxiety / suicidal
Endocrine: diabetes / thyroid problems
Hematologic / Lymphatic: low blood count / blood disorders
History of Cancer: yes / no type: __________________________________________
Surgeries or Hospitalizations Date Surgeries or Hospitalizations Date
1. __________________________
_______
5. ____________________________
_______
2. __________________________
_______
6. ____________________________
_______
3. __________________________
_______
7. ____________________________
_______
4. __________________________
_______
8. ____________________________
_______
© 2010 All Rights Reserved
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PATIENT MEDICAL HISTORY FAMILY HISTORY MEDICATIONS

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Completed 17 March 2021

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