Patient Medical History Form Home 5 Patient Medical History Form Step 1 of 9 11% Name* First Last Preferred Name/Nickname Email Ethnicity/Race Preferred Language Appointment Reminder Preference Date of Birth MM slash DD slash YYYY Right or Left Handed? Right Left Age Sex Male Female Today's Date MM slash DD slash YYYY Purpose of Your Visit Social HistoryOccupation Employer Employer PhoneMarital Status Single Married Divorced Widowed Significant Other Do you have children? Yes No How Many Children? Do you live alone? Yes No Who lives with you? Highest level of education Do you smoke? Yes No No, I quit For how many years? How many packs per day? Did you smoke cigars or a pipe? Yes No How many years ago did you quit? How many years did you smoke for? How many packs of cigarettes per day did you smoke? Do you drink alcohol? No, never (or rarely) Yes, occasionally Yes, with some regularity Has drinking ever been a problem for you? Yes No Please elaborate below if you wishHave you ever used / abused illicit drugs? No, never Yes How long ago? Please describe the nature or type of drug(s) you have used below Medical HistoryPlease indicate if you have had or been diagnosed with any of the following conditionsAnemia or low blood counts? No / never Yes Anxiety? No / never Yes Arthritis? No / never Yes Asthma? No / never Yes Cancer? No / never Yes Cataracts? No / never Yes Heart disease or congestive heart failure? No / never Yes Blood clotting disorder or easy bleeding? No / never Yes Bipolar Mood Disorder? No / never Yes COPD? No / never Yes Depression? No / never Yes Diabetes? No / never Yes Emphysema? No / never Yes Reflux disease (GERD)? No / never Yes Glaucoma? No / never Yes Heart Murmur? No / never Yes HIV / AIDS? No / never Yes Hepatitis? No / never Yes Hypertension? No / never Yes High cholesterol (hypercholesterolemia)? No / never Yes Kidney Disease (renal impairment)? No / never Yes Kidney stones? No / never Yes Meningitis? No / never Yes Coronary artery disease or heart attack? No / never Yes Osteoporosis or osteopenia? No / never Yes Seizures? No / never Yes Sickle cell anemia? No / never Yes Stroke or TIA? No / never Yes Thyroid disease? No / never Yes Tuberculosis? No / never Yes Ulcer disease? No / never Yes Sleep apnea? No / never Yes Neuropathy or nerve damage? No / never Yes Degenerative disc disease or pinched nerve? No / never Yes Urinary incontinence? No / never Yes Crohn's Disease or Ulcerative Colitis? No / never Yes Surgical HistoryPlease indicate if you have had any of the following surgeries. Please specify the date (year) or specific type of surgery, wherever you are able:Appendectomy? No / never Yes Brain Surgery? No / never? Yes Breast surgery? First Choice Second Choice Third Choice Heart surgery? No / never Yes Gall bladder surgery? No / never Yes Colon surgery No / never Yes Cosmetic surgery? No / never Yes C-section No / never Yes Eye surgery No / never Yes Fracture surgery? No / never Yes Hernia surgery? No / never Yes Hysterectomy or ovarian surgery? No / never Yes Joint replacement surgery? No / never Yes Prostate surgery? No / never Yes Spine surgery? No / never Yes Tubal ligation? No / never Yes Vasectomy? No / never Yes Family HistoryYour MotherMother's Name Mother's StatusLivingDeceasedMother's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Your FatherFather's Name Father's StatusLivingDeceasedFather's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Your SisterSister's Name Sister's StatusLivingDeceasedSister's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Your BrotherBrother's Name Brother's StatusLivingDeceasedBrother's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Your DaughterDaughter's Name Daughter's StatusLivingDeceasedDaughter's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Your SonSon's Name Son's StatusLivingDeceasedSon's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Your Maternal Grand MotherMaternal Grand Mother's Name Maternal Grand Mother's StatusLivingDeceasedMaternal Grand Mother's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Your Maternal Grand FatherMaternal Grand Father's Name Maternal Grand Father's StatusLivingDeceasedMaternal Grand Father's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Your Paternal Grand MotherPaternal Grand Mother's Name Paternal Grand Mother's StatusLivingDeceasedPaternal Grand Mother's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Your Paternal Grand FatherPaternal Grand Father's Name Paternal Grand Father's StatusLivingDeceasedPaternal Grand Father's Health Issues No known problems Alcohol abuse Arthritis Asthma Breast cancer Cancer Colon cancer COPD Depression Diabetes mellitus Drug abuse Heart disease Hyperlipidemia Hypertension Kidney disease Learning disabilities Mental illness Miscarriage Prostate cancer Stroke Dementia Pharmacy Name Pharmacy Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Pharmacy Phone NumberCurrent MedicationsPlease list all of your current medications, including pain medications, p.r.n. medications, over-the-counter medications, vitamins and supplements. Please include the dose and frequency, if known. Please indicate approximately how long you have taken each medication. Use additional space, if needed.MedicationDose / FrequencyHow long taken? Medication AllergiesPlease list allergies you have had to medications, including over the counter medications and supplements:MedicationNature of Allergy / Reaction Other Medical / Surgical HistoryPlease list any other illness or surgical procedures you have had in the past, and indicate approximately when each occurred:Medical illness, conditions, or previous surgeryApproximate date of occurence I certify that the information provided is accurate to the best of my knowledgePatient Signature Date MM slash DD slash YYYY
