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Patient Medical History Form

Patient Medical History Form to be filled out at initial Doctor's Office visit.

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Medical History Template

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Patient Medical History Information

Date: ____/____/______

Name: ___________________________________________________

Social Security Number: _________________________________

Date of Birth: __________________________________________

Past Medical History:

Previous Physician Name: ________________________________

Date of Last Exam: ____/____/______

Have you ever been hospitalized? [__] Yes [__] No If Yes, what for? _____________

Have you ever been tested for hepatitis A, B or C? [__] Yes [__] No Which virus? ____________

Have you ever been vaccinated for hepatitis B? [__] Yes [__] No

If yes, date the vaccine series was completed ____/____/______

Have you been vaccinated for hepatitis A? [__] Yes [__] No

If yes, date the vaccine series was completed ____/____/______

Last Tuberculosis (TB) Screening? ____/____/______

Result of TB screening: [__] Positive [__] Negative

If positive TB screen, date of last chest x-ray: ____/____/______

Result of chest x-ray: [__] Positive [__] Negative

Have you had a sexually transmitted disease? [__] Yes [__] No Diagnosis: ___________

Which of the following conditions are you currently being treated or have been treated for in the past:

[__] Heart Disease [__] High Cholesterol [__] High blood pressure [__] Low blood pressure

[__] Heartburn [__] Anemia [__] Swollen Ankles [__] Shortness of breath [__] Asthma

[__] Lung problems [__] Sinus problems [__] Seasonal allergies [__] Tonsillitis [__] Ear problems

[__]Eye disorder [__] Seizures [__] Stroke [__] Headaches [__] Neurological problems

[__] Depression [__] Psychiatric Care [__] Diabetes [__] Kidney / Bladder [__] Liver problems

[__] Arthritis [__] Cancer [__] Ulcers [__] Thyroid problems

Please describe any current or past medical treatment not listed above:



Please list any past surgeries you have had:




Are you allergic to penicillin or any other drug? [__] Yes [__] No

Please list: _____________________________________________________________________

Medications: Please list: _____________________________________________________________________

Social and Preventative History:

Do you currently smoke or chew tobacco? [__] Yes [__] No

If No, Have you in the past? [__] Yes [__] No How many packs per day? ____________________

Do you drink alcohol, beer, or wine? [__] Yes [__] No

If No, Have you in the past? [__] Yes [__] No How many drinks per week? __________________

Do you currently drink coffee and / or tea? [__] Yes [__] No If yes, how man cups per day? ____

Do you exercise daily / weekly? [__] Yes [__] No

Do you use seatbelts while driving? [__] Yes [__] No

Do you wear a helmet while riding a bike? [__] Yes [__] No

Family History:

Relative Living Age or Age at Death Serious Illnessess
Mother [__] Yes [__] No    
Father [__] Yes [__] No    
Sisters [__] Yes [__] No    
  [__] Yes [__] No    
  [__] Yes [__] No    
Brothers [__] Yes [__] No    
  [__] Yes [__] No    
  [__] Yes [__] No    

Has any member of your family (including children and parents) had any of the following illnesses?

Anemia or Blood Disease: [__] Yes [__] No Family member:____________________

Cancer: [__] Yes [__] No Family member:_____________________________________

Diabetes: [__] Yes [__] No Family member:___________________________________

Glaucoma: [__] Yes [__] No Family member:___________________________________

Heart Disease: [__] Yes [__] No Family member:______________________________

High Blood Pressure: [__] Yes [__] No Family member:________________________

HIV Disease / AIDS: [__] Yes [__] No Family member:_________________________

Mental Illness / Depression: [__] Yes [__] No Family member:________________

Stroke: [__] Yes [__] No Family member:_____________________________________

Other Serious Illness: _____________________________________________________

Females: Gynecological History:

How many times have you been pregnant? _____________________________________

Date of last Pap Smear: ____/____/______

Have you had an abnormal Pap Smear? [_] Yes [_] No Diagnosis: ___Follow Up: _

Have you had a sexually transmitted disease? [__] Yes [__] No Diagnosis: ____

Date of Last Mammogram: ____/____/______ Mammogram results: _________________

Have you ever had a breast biopsy? [__] Yes [__] No Biopsy results: _________

By signing below, I do hereby certify that to the best of my knowledge all the above information on this form that I have supplied is complete and true.

Patient / Legal Guardian Signature

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