Medical History Form

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1 Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart Disease High Cholesterol Arthritis Cancer Kidney Disease Glaucoma Asthma Allergies Migraine Headache Anemia Bronchitis/Emphysema Obesity Acid Reflux Other: Women Only: Age of first menstrual cycle Date of last period Do you have a history of irregular menstrual cycles? (Y / N) Are you currently on birth control? If yes, what type / name? Number of pregnancies? # of live births? # of Miscarriages? Have you had an abnormal Pap result? If yes, when? (year) How often do you self-breast exam? (circle one) Never Rarely Weekly Monthly SURGICAL & HOSPITALIZATION HISTORY List all of surgeries or hospitalizations (with cause) you have had in the past 10 years? _ SOCIAL How much do you smoke? How many years? How much alcohol (including beer) do you drink in week? Have you used or currently use recreational drugs? YES NO If yes how long Please list people you currently live with: Are you: Single Married Divorced Other? Is your health (check one) Excellent Good Poor Have you ever been a victim of domestic violence? Including: physical, psychological, emotional, economic, and sexual abuse? Do you have a gun in your house? YES NO

2 What is your occupation? Please include any unusual or potentially dangerous exposures you might have at work. Please list types of exercise you participate in How often do you exercise per week? How long do you exercise during this time? SEXUAL Were you under age 18 when you had your first sexual contact? YES NO How many sexual partners have you had in the past? Male Female Have you ever had a sexually transmitted disease? YES NO If yes, please list type(s) FAMILY HISTORY Please list if any family members have had the following illness. Please list their relation to you. Family Member Current Age Mother Father Sister Sister Brother Brother **Continue on back of page if more** Living? (Y /N) Medical Conditions Cause of Death (if deceased) Age at Death HEALTH MAINTENANCE Please list the year of your last screening test below: (please indicate if there were any abnormal results) PAP smear: Mammogram: Colonoscopy: Eye Exam: Cholesterol Test: Prostate Exam: Dental Exam: Blood Work: Immunizations/vaccine- Please list the year of your last: Tetanus Shot: Flu Shot: Pnemovax (Pneumonia shot): Hepatitis A Hepatitis B: Chicken Pox: TB Skin Test: Medications currently taking (with dosage): Medication Dosage The time(s) of the day you take it

3 Vitamins or supplements currently taking: Allergic reactions to medicine or foods: Please list the TYPE OF REACTION. Medication / Food Allergy _ Reaction Please check any CURRENT symptoms with a C and any PAST symptoms with a P GENERAL MUSCULOSKELETAL MEN Fever Joint Pain Difficulty urinating Weight Loss Muscle weakness Trouble with erections Weight Gain Back Pain Change in urination EYES Trouble Walking WOMEN Vision Changes Cramping PMS Double Vision SKIN Cramping Eye Pain/Irritation Rash Abnormal vaginal bleeding Yellow Eyes (jaundice) New skin growths Irregular menstrual cycle Change in Moles Lump in breast EARS, NOSE, THROAT Warts Abnormal discharge from nipples Hearing Loss Skin Cancer Uterine fibroids Sinus Pain Itchy Skin Excessive menstrual bleeding Nose Bleeds Dry Skin Hot flashes Seasonal Allergies Bleeding Mood changes Lumps in mouth Oily Skin Heavy sensation in abdomen Jaw pain Brittle nails Vaginal irritation

4 Ears, Nose, Throat Teeth or gum pain Ringing in Ears NEUROLOGIC Seizures Numbness Soars in Mouth Stroke ENDOCRINE Difficulty swallowing Twitching Hair Loss Painful Swallowing Headaches/Migraines Feeling or Cold Postnasal Drip Dizziness Excessive Thirst Sneezing BEHAVIORAL Frequent Thirst CARDIOVASCULAR Trouble Sleeping Frequent Urination Chest Pain Trouble Concentrating Excessive Hair Growth Palpitations Depression HEMATOLOGIC Swelling of the Legs Feeling blue or down Unusual Bleeding Irregular heartbeat Marital problems Unusual Bruising Abnormal EKG Anxiety Anemia High Cholesterol Mood swings Enlarge Lymph Nodes Shortness of Breath Panic Attacks GENITOURINARY RESPIRATORY GASTROINTESTINAL Kidney Stones Wheezing Stomach Pain Blood in Urine Coughing Ulcer Urinary Tract Infection Coughing up Blood Pneumonia Asthma Shortness of Breath Constipation Diarrhea Hemorrhoids Blood in Stool

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