MEDICAL HISTORY FORM
Information Section
Name
*
(Please print name in full)
TODAYS' DATE
DOB
HIEGHT
WEIGHT
PHARMACY NAME
*
PHARMACY PHONE NUMBER
*
REASON FOR TODAYS VISIT
PAST MEDICAL HISTORY
Please Choose
*
Hypertension
Allergies
Back Problems
COPD
Cholesterol
Dementia
GERD
Migraines
Stroke
Anemia
Anxiety
HIV
Diabetes
Sinus
Tuberculosis
DVT
Asthma
Ear Problems
Seizures
Heart Problems
Thyroid Disease Osteoporosis Y Nervous
CHF
Kidney Disease
Depression
Epilepsy
Gout
None
SURGICAL HISTORY. Please list:
Last Radiology:
Chest x-ray
EKG
Colonoscopy
Bone Density
Females Only:
LMP
Pap Smear
Mammogram
Number of pregnancies
Live births
Miscarriage
Abortions
Males Only:
Males Only
Date of last prostate exam
FAMILY MEDIAL HISTORY
FAMILY MEDIAL HISTORY
Mother
Father
Brother
Sister
High Blood Pressure
Depression
High Cholesterol
Stroke
Diabetes
Breast Cancer
Anxiety
Hypothyroidism
Other
Appointment
SOCIAL HISTORY
Tobacco Use
Never
In the Past
Presently
Alcohol Use
Daily
Occasional
None
Other Substance use or Abuse?
ALLERGIC TO LATEX
*
Yes
No
ALLERIC TO MEDICATION ( please add which medications)
*
Yes
No
PLEASE LIST
CURRENT MEDICATION. (Please write "none" if you are not taking any).
*
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