Patient Medical History Information
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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:
________________________________
________________________________
Allergies:
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:
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Relative
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Living
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Age or Age at Death
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Serious Illnessess
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Mother
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[__] Yes [__] No
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Father
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[__] Yes [__] No
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Sisters
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[__] Yes [__] No
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[__] Yes [__] No
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[__] Yes [__] No
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Brothers
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[__] Yes [__] No
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[__] Yes [__] No
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[__] Yes [__] No
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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.
_______________________ Date_____
Patient / Legal Guardian Signature
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