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g or Livin g or PAST MEDICAL HISTORY

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PAST MEDICAL HISTORY
Date:
Name:
Date of Birth:
DRUG ALLERGIES
FAMILY HISTORY
FATHER:
Livin
g
or
Deceased
Age
MOTHER:
Livin
g
or
Deceased
Age
SIBLINGS:
Livin
g or
Deceased
Age
CHILDREN:
Living or
Deceased
Age
FAMILY HISTORY
Father
Mother
Siblings
Children
Heart Disease
High blood pressure
Stroke
Cancer
Glaucoma
Diabetes
Epilepsy/Seizures
Bleeding disorder
Kidney disease
Thyroid disease
Mental illness
Arthritis
HOSPITALIZATION OR SURGERY
REASON
DATE
PAST MEDICAL HISTORY
Allergies/Hay fever
Anemia
Arthritis
Bowel irregularity
Bronchitis
Chest Pain
Chronic rashes
Depression
Dizziness/Fainting
Diabetes
Gallbladder disease
Gout
Headache/Migraines
Heart murmur
Heart palpitations
Hepatitis
High cholesterol
High triglycerides
Hypertension
Nervousness
Pneumonic
Prostate disease
Rheumatic fever
Seizure disorder
Sexual/Menstrual dysfunction
Shortness of Breath
Ulcer
Date of last Immunization
Flu Vaccine
Tetanus
Pneumonia
MMR
PPD
Other
HABITS
Smoke now?
Yes No
Coffee: cups daily?
Ever smoked?
Yes No
Other caffeine?
Packs Daily?
Exercise routine?
How long?
Sleep patterns?
Alcohol?
Yes
No
Fat intake?
Type?
Salt intake?
Diet:
Amount?
Street drugs?
Yes
No
Type?
Contact with blood/body fluids at work?
Yes No
Advanced Directive?
Yes
No
If yes, please provide copy
MEN ONLY
Last PSA:
Month
Year
WOMEN ONLY
Menstruation:
First at age
days between periods
Period last
days
Flow is:
light
moderate
heavy
Date of last period?
Pregnant?
Yes
No
Planning?
Yes
No
Total # Pregnancies
Age of youngest child?
Type of Birth Control?
Date of last Pap Smear?
Date of last Breast Exam
Date of last Mammogram
Please list any additional information
about
yourself that you feel will
help
the doctor
in
your evaluation:
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Completed 3 February 2022

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