Microsoft Word - Medical History Form.doc



Medical History FormDirections: Please answer the following questions to the best of your knowledge.PATIENT INFORMATIONLast NameFirst NameMiddlePrimary LanguageSocial Security No.Street AddressCityStateZipOK to Send Letter??Yes? NoSex:? Male? FemaleHome PhoneOK to Call?? Yes? NoWork PhoneOK to Call?? Yes? NoIf No, How can you be reached?Date of BirthMarital Status:? Single without partner?Single with partner Length of Time: ? Married? Separated? Divorced? WidowedSexual Orientation? Heterosexual? Homosexual? BisexualChildren: ? Yes ? NoHow Many?Number of Persons Living in Your Home?Race/ EthnicityEmergency Contact PersonPhone NumberRelationshipPRIMARY PHYSICIAN(S)NameNameNameAddressAddressAddressPhone:Phone:Phone:Medication Allergies? ? Yes ? NoSubstance or Food Allergies? ? Yes? NoIf yes, what medication(s) If yes, what substance(s) FAMILY HISTORY:Please check the box if your family has a history of:Diabetes? High Blood Pressure? Heart Attack, Heart Disease? Blood Clots or Stroke? TuberculosisCancer? Alzheimer’s? Family History Unknown? Mental Illness? Epilepsy/SeizureAny other major conditions? If you answered Yes to any of the above, please explain: Are you currently being treated for medical conditions? ? Yes ? Noif yes, please list: MEDICATIONS(List more on separate page if necessary)Current MedicationsFor what condition?DosageFrequencyDate startedComments / Problems / ConcernsPast Medications / For what condition? (List sedatives, pain medications, sleeping pills, antidepressants, etc)Social/Sexual Risk HistoryYes? NoDo you smoke? If yes, how many cigarettes per day?Yes? NoDo you use alcohol? If yes, how often, how much?Yes? NoDo you or your partner(s) use drugs?If yes, how much, how often?Ever injected drugs? (explain)Yes? NoHave you ever had or would you like help now with an alcohol or drug problem?Yes? NoWould you like to discuss problems related to a rape or emotional/physical/sexual abuse?Yes? NoAre you now or have you ever been in a relationship where you have been physically hurt or threatened?REVIEW OF SYSTEMS:Please check the box if you currently have or have ever had the following1. GeneralProductive cough (3 weeks or more)Current ? PastUnusual discharge (vaginal or from penis)Current ? PastDry, unproductive cough (3 wks or more)Current ? PastBloody or painful urinationCurrent ? PastShortness of breathCurrent ? PastDark, bloody or painful bowel movementsCurrent ? PastChest painCurrent ? PastHepatitis ACurrent ? PastRecurrent night sweats, chills, feversCurrent ? PastHepatitis BCurrent ? PastSwollen glands (neck, armpits or groin)Current ? PastHepatitis CCurrent ? PastPersistent weight loss without dietingCurrent ? PastChronic FatigueCurrent ? PastWeight problem/eating disorderCurrent ? PastCancerCurrent ? PastTuberculosis: Ever Tested? ? Yes ? No Date and result of last test: If Positive, did you have a chest x-ray? Ever Treated? ? Yes ? No Date(s) and type(s) of treatment: HIV:Ever Tested? ? Yes ? No Would you like information regarding HIV/AIDS or testing sites? ? Yes ? NoREVIEW OF SYSTEMS:Please check the box if you currently have or have ever had the following:2. Skin7. GastrointestinalAllergies/Rash/ItchingCurrent ? PastRecurrent nausea/vomiting/diarrheaCurrent ? PastPsoriasis / EczemaCurrent ? PastStomach/bowel problemsCurrent ? PastGall bladder diseaseCurrent ? Past3. EyesPancreatitisCurrent ? PastVision problemsCurrent ? PastDiabetes / hyperglycemia / hypoglycemiaCurrent ? PastEye infectionsCurrent ? PastEncopresis (incontinent of feces)Current ? Past4. Ears, Nose, Throat, Lungs8. GenitourinaryHearing problemsCurrent ? PastBladder/kidney problems or infectionCurrent ? PastTeeth/gum problems or diseaseCurrent ? PastIncontinence (unable to control bladder)Current ? PastFrequent nosebleedsCurrent ? PastEnuresis (bedwetting)Current ? PastRecurrent sinusitisCurrent ? PastSexually transmitted diseases:Frequent sore throatsCurrent ? Past Gonorrhea Syphilis HerpesRecurrent PneumoniaCurrent ? Past Chlamydia TrichomonasAsthmaCurrent ? Past HPV or genital warts5. CardiacFemales:Palpitations/arrhythmiaCurrent ? PastMenstrual DifficultiesCurrent ? PastHeart disease/murmurCurrent ? PastCycle: Regular Irregular High blood pressure / Low blood pressureCurrent ? PastPre-Menopause Menopause High cholesterolCurrent ? PastProblems/infection of tubes/ovaries/uterusCurrent ? PastThrombophlebitis/blood clotsCurrent ? PastAbnormal Pap Smear(s)Current ? PastNumber of pregnancies 6. NeurologicalNumber of births StrokeCurrent ? PastProblems with pregnancies/births (explain)Frequent Headaches or MigrainesCurrent ? PastSeizures/EpilepsyCurrent ? PastBreast disease / tumor / surgery (explain)Weakness/paralysis/unsteady walkingCurrent ? PastDizziness/confusion/wanderingCurrent ? PastMiscellaneous:Forgetfulness/memory lapse/memory lossCurrent ? PastAnemia / blood disorderCurrent ? PastArthritisCurrent ? PastOther conditions / problems not listed:Sleep disturbanceCurrent ? PastI certify that I have answered these questions to the best of my knowledgePatient Signature: Date: CLINICIANS NOTES (CLARIFICATIONS / FOLLOW UP / ETC)Reviewed by (Clinician):Date: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download