NEW PATIENT

MEDICAL HISTORY FORM

Full Name: Date:

Birth Date: Age:

ALLERGIES o NO ALLERGIES

ALLERGY ALLERGIC REACTION

MEDICATIONS
MEDICATIONS DOSE TIMES PER DAY
(Please list ALL) (Mg., pill, etc.)

If you need more room to list medications, please write them on a blank sheet of paper with the required information

HEALTH MAINTENANCE SCREENING TEST HISTORY

Cholesterol Date: Facility/Provider: Abnormal Result? Y N

Colonoscopy/Sigmoid Date: Facility/Provider: Abnormal Result? Y N

Mammogram Date: Facility/Provider: Abnormal Result? Y N

Pap Smear Date: Facility/Provider: Abnormal Result? Y N

bone density Date: Facility/Provider: Abnormal Result? Y N

VACCINATION HISTORY
Last Tetanus Booster or TdaP: Last Pnuemovax (Pneumonia):

Last Flu Vaccine: Last Prevnar:

Last Zoster Vaccine (Shingles):

PERSONAL MEDICAL HISTORY
DISEASE/CONDITION CURRENT PAST COMMENTS

Alcoholism/Drug Abuse

Asthma

Cancer (type:_________________________________)

Depression/Anxiety/Bipolar/Suicidal

Diabetes (type:_______________________________)

Emphysema (COPD)

Heart Disease

High Blood Pressure (hypertension)

High Cholesterol

Hypothyroidism/Thyroid Disease

Renal (kidney) Disease

Migraine Headaches

Stroke

Other:

Other:

SURGERIES
TYPE (specify left/right) Date Location/Facility

WOMEN’S HEALTH HISTORY

Date of Last Menstrual Cycle: Age of First Menstruation: _____ Age of Menopause: _____

Total Number of Pregnancies: Number of Live Births:

Pregnancy Complications:

Patient Name: DOB:

family MEDICAL HISTORY o No Significant Family History is Known

(type:_____________)

Other:____________

Other:____________

Other:____________
Alcohol/Drug Abuse

High Blood Pressure

Emphysema (COPD)

Depression/Anxiety

High Cholesterol

Thyroid Disease
Bipolar/Suicidal

Kidney Disease
Heart Disease
Early Death

Migraines
Diabetes
Asthma

Cancer

Stroke
4 check all that apply

Mother

Father

Brother

Sister

Child

MGM

MGF

PGM

PGF

Other:__________________

SOCIAL HISTORY
Occupation (or prior occupation): o Retired o Unemployed o LOA o Disabled

Employer: Years of Education or Highest Degree:

If employed, do you work the night shift? Y N N/A

Marital Status (check one): o Single o Partner o Married o Divorced o Widowed o Other:_______________________

Do you have children? Y N If yes, how many?

OTHER HEALTH ISSUES

Tobacco Use Smoke Cigarettes? Y N (If you never smoked, please move to Alcohol /Drug Use)

Current: Packs/day _____ # of Years _____ Past: Quit Date: __________________ Packs/day _____ # of Years _____

Other Tobacco (check one): o Pipe o Cigar o Snuff o Chew

alcohol/drug Use Do you drink alcohol? Y N o Beer o Wine o Liquor # of Drinks/week:

Do you use marijuana or recreational drugs? Y N Have you ever used needles to inject drugs? Y N

Have you ever taken someone else’s drugs? Y N

Patient Name: DOB:

OTHER HEALTH ISSUES continued...
sexual activity Sexually involved currently? Y N (If no sexual history, please continue to Exercise)

Sexual partner(s) is/are/have been: o Male o Female

Birth control method: o None o Condom o Pill/Ring/Patch/Inj/IUD o Vasectomy

exercise Do you exercise regularly? Y N (If you answered no, please move to Sleep)

What kind of exercise? Duration: How long (min.): _______ How often: ________

sleep How many hours, on average, do you sleep at night (or during the day, if working night shift)?

DIET How would you rate your diet? o Good o Fair o Poor Would you like advice on your diet? Y N

safety Do you use a bike helmet? Y N Do you use seat belts consistently? Y N

Working smoke detector in home? Y N If you have guns at home, are they locked up? Y N
Have you completed an Advance Directive for Health Care (ADHC),
Is violence at home a concern for you? Y N Living Will, or Physical Orders for Life Sustaining Therapy (POLST)? Y N

OTHER PROVIDERS/SPECIALISTS
SPECIALIST NAME LAST VISIT

Cardiology

Gastroenterologist (GI)

OB/GYN

Neurology

Pulmonary

Other:_________________________

Other:_________________________

ADDITIONAL INFORMATION
Have you traveled outside of the country in the last 30 days? Y N If yes, where?

Have you served in the military? Y N If yes, how long and what branch?

Were you deployed? Y N If yes, where?

Patient Name: DOB:

REVIEW OF SYSTEMS 4 check all that apply

CONSTITUTION CARDIOVASCULAR SKIN

Activity change Chest pain Color change
Appetite change Leg swelling Pallor
Chills Palpitations Rash
Diaphoresis Gastrointestinal Wound
Fatigue Abdominal distention ALLERGY/IMMUNO
Fever Abdominal pain Environmental allergies
Unexpected weight change Anal bleeding Food allergies
HEAD, EAR, NOSE & THROAT Blood in stool Immunocompromised
Congestion Constipation NEUROLOGICAL
Dental problem Diarrhea Dizziness
Drooling Nausea Facial asymmetry
Ear discharge Rectal pain Headaches
Ear pain Vomiting Light-headedness
Facial swelling ENDOCRINE Numbness
Hearing loss Cold intolerance Seizures
Mouth sores Heat intolerance Speech difficulty
Nosebleeds Polydipsia Syncope
Postnasal drip Polyphagia Tremors
Rhinorrhea Polyuria Weakness
Sinus pressure Genitourinary HEMATOLOGIC
Sneezing Difficulty urinating Adenopathy
Sore throat Dysuria Bruises/bleeds easily
Tinnitus Enuresis pSYCHIATRIC
Trouble swallowing Flank pain Agitation
Voice change Frequency Behavior problem
EYES Genital sore Confusion
Eye discharge Hematuria Decreased concentration
Eye itching Penile discharge Dysphoric mood
Eye pain Penile pain Hallucinations
Eye redness Penile swelling Hyperactive
Photophobia Scrotal swelling Nervous/anxious
Visual disturbance Testicular pain Self-injury
RESPIRATORY Urgency Sleep disturbance
Apnea Urine decreased Suicidal ideas
Chest tightness MUSCULAR
Choking Arthralgias
Cough Back pain
Shortness of breath Gait problems
Stridor Joint swelling
Wheezing Myalgias
Neck pain
Neck stiffness

Patient Name: DOB: