Patient Medical History Form

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Patient Medical History Form Patient Name: To help the doctor serve you better, please complete the information below. Thank you! Allergies: No known Allergies (If yes, please list all Drug, Food, and Environmental Allergies below:) Medications: Preferred Pharmacy: Location: Please list all current Over the Counter and Prescribed Medications with their corresponding dosages: (if known) NAME OF MEDICATION STRENGTH HOW OFTEN? Personal Medical History: Did you in the Past, or do you Currently have problems with any of the following? (Please check all that apply to YOU) and tell us, to the best of your knowledge: CONDITION PAST CURRENT DATE/ AGE ONSET: DATE/AGE RESOLVED: ABDOMINAL PAIN- CHRONIC AGITATION ALCOHOL ABUSE/ ADDICTION ALLERGIES ANEMIA ARTHRITIS ASTHMA BACK PAIN-RECURRENT BLEEDING EASILY BLOOD IN URINE/HEMATURIA BLOODY OR TARRY STOOLS BONE FRACTURE OR JOIN INJURY CANCER CATARACTS CHEST PAIN CHICKEN POX CHRONIC COUGH CHRONIC FATIGUE COLD NUMB FEET COLITIS CONSTIPATION CROHN S DISEASE DECREASE IN FLOW OR FORCE OF URINE DECREASED HEARING DEPRESSION/MOODINESS DIABETES DIARRHEA DIFFICULTY SWALLOWING DIVERTICULOSIS DIZZY SPELLS DOUBLE OR BLURRED VISION

Patient Name: CONDITION PAST CURRENT DATE/ AGE ONSET: DATE/AGE RESOLVED: DRUG ABUSE/ADDICTION EAR INFECTIONS- FREQUENT ECZEMA EPILEPSY EYE PAIN FAILING VISION FAINTING SPELLS FEELINGS OF WORTHLESSNESS FOOT PAIN GALL BLADDER TROUBLE GERMAN MEASLES GLAUCOMA GOUT HEADACHES/MIGRAINE HEART DISEASE HEART MURMUR HEARTBURN HEMORRHOIDS HERNIA HERPES HIGH BLOOD PRESSURE HIGH CHOLESTEROL HOARSENESS- PROLONGED IRREGULAR PULSE/HEART PALPITATIONS JAUNDICE/ HEPATITIS KIDNEY STONES LEG PAIN- WHEN WALKING LOSS OF APPETITE RECENT LOSS OF CONTROL OF BLADDER-URINATION MEASLES MEMORY LOSS MENTAL ILLNESS MUMPS NERVOUSNESS NOSE BLEED- FREQUENT OR RECURRENT NUMBNESS-TINGLING SENSATIONS OSTEOPOROSIS OTHER: PAINFUL URINATION PEPTIC ULCER PERSISTENT NAUSEA/ VOMITING PHOBIAS PNEUMONIA/ PLEURISY POLIO PSORIASIS RASHES/HIVES RECENT HAIR LOSS

Patient Name: CONDITION PAST CURRENT DATE/ AGE ONSET: DATE/AGE RESOLVED: RECENT UNEXPECTED WEIGHT CHANGE RHEUMATIC FEVER RINGING IN EAR SCARLET FEVER SEVERE DEPRESSION SHORTNESS OF BREATH WHILE ACTIVE SHORTNESS OF BREATH WHILE AT REST SINUS TROUBLE SLEEPING DIFFICULTY SORE THROAT- FREQUENT STROKE SUICIDAL IDEATIONS SWOLLEN ANKLES THYROID DISEASE TREMOR TROUBLE WITH CONCENTRATION TUBERCULOSIS URETHRAL DISCHARGE URINATION MORE THAN TWICE AT NIGHT URINE/BLADDER INFECTIONS FREQUENT VARICOSE VEINS/PHLEBITIS VENEREAL DISEASE WHEEZING Procedures and Surgeries: NONE Procedure/ Surgery: (If yes, please list all Procedures/Surgeries and indicate when. Ex.: Tonsillectomy-2005 When: Family History: Does any of the below condition apply to your relative(s)? If so, please mark (x) accordingly. TYPE MOTHER FATHER SISTER BROTHER Maternal Alcohol Abuse Allergies Anemia Arthritis Asthma Bleeding Easily Cancer: 1. 2. 3. 4. Epilepsy Glaucoma Headache/ Migraine Maternal

Patient Name: TYPE MOTHER FATHER SISTER BROTHER Maternal Heart Disease High Blood Pressure High Cholesterol Mental Illness Osteoporosis Severe Depression Stroke Thyroid Disease Other: Maternal Social History: ALCOHOL USE: TYPE (PLEASE CIRCLE) AMOUNT AND FREQUENCY CURRENT PAST NEVER QUIT SINCE: TOBACCO USE: TYPE (PLEASE CIRCLE) AMOUNT AND FREQUENCY CURRENT PAST NEVER QUIT SINCE: SUBSTANCE/DRUG USE: TYPE (PLEASE CIRCLE) AMOUNT AND FREQUENCY CURRENT PAST NEVER QUIT SINCE: EXERCISE AND PHYSICAL ACTIVITY: TYPE (PLEASE CIRCLE) AMOUNT OF TIME AND FREQUENCY NONE OCCASIONAL REGULAR Pregnancies: Please complete below for all pregnancies including abortions, miscarriages, etc. 1. 2. 3. 4. 5. 6. 7. 8. DATE/ TIME NUMBER OF WKS. PREGNANT PREGNANCY/ DELIVERY OUTCOME LENGTH OF LABOR SEX OF THE BABY WEIGHT ANESTHESIA HOSPITAL Do you have Living Will or Advanced Directive? YES NO I certify that the information contained herein is complete and accurate to the best of my knowledge. Patient Signature Date

Patient Name: Employment and Education Status: Work Hazards: Activity Level: Employed Disability Part-Time Retired Student Unemployed Other: Do you operate any hazardous equipment? Y / N Hazardous Materials Heavy Lifting/Twisting Loud Noises Medical/Clinical Work Repetitive Motion Shift/Night Work Vibration Other: Desk/Office Occasional Physical Work Moderate Physical Work Heavy Physical Work Other: Previous Employment/School: Highest Education: School Concerns: Additional Information: None Elementary School High School/GED Middle School Some College Bachelor s Degree Master s Degree Adv. Graduate or Ph.D. Home and Environment Learning Social Communication Health Cultural Other: Additional Information: Marital Status: Lives With: Living Situation: Single Married Married (Living Together) Separate Never Married Divorce Widowed Annulled Self Children Family Father Mother Roomate(s)/ Friend(s) Siblings Home/Independent Home with Assistance Physical Work Homeless/Shelter Life Partner Foster Family Significant Other Grandparents Spouse Other: Other: Other: Number of Children: E n v i r o n m e n t S c r e e n i n g Have you experience any abuse in your house hold? Do you feel unsafe at home? Do you have a safe place to go? Do you have Family/Friends available to help? Y / N Y / N Y / N Have you notified any Agencies about your abuse? Y / N Agency(s)/Others Notified:

Patient Name: Nutrition and Health Briefly write your routine diet: Type of Diet: OTHER: Regular Calorie Restricted Diabetic Dysphagia Diet Ketogenic Diet Kosher Low Carbohydrate Low Fat Low Sodium Renal Total Parenteral Nutrition Vegetarian Other: Diet Restrictions: Caffeine intake amount: Do you want to lose weight? Y / N Vitamins/Alternative Health Eating Disorders: OTHER: Vitamins/Supplements: Uses Alternative Healthcare: Bulimia Anorexia Nervosa Overeating Other: Sleeping concerns? Y / N Feeling highly Stressed? Y / N Exercise and Physical Activity Exercises Exercise Type: Self Assessment How many times per week? Never 1-2 times 3-4 times 5-6 times Daily Other: _ Duration (Average # of minutes): Aerobics Bicycling Organized Team Sports PE Class Running Swimming Walking Weight Lifting Yoga Other: Poor Condition Fair Condition Good Condition Excellent Condition Other/Comment:

Patient Name: Sexual Activity Activity Orientation: Contraceptive Use Details Are you Sexually Active? Y / N When were you first active? Age: Number of lifetime partners: Self describe orientation: Heterosexual Homosexual Bisexual Transgender Other: Abstinence Birth Control Implant Birth Control PATCH Birth Control PILL Birth Control SHOT Condoms Intrauterine Device Vaginal Ring None Number of current partners: Do you use condoms? Y / N Other Contraceptive Use/Comment: _ History of Abuse Orientation: Other Related Concerns: Have you ever been sexually abused? Y / N Comment: _ Self describe orientation: Heterosexual Homosexual Bisexual Transgender Other:

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