MEDICAL HISTORY

 

DATE__________________

 

PATIENT NAME__________________________________BIRTHDAY________________AGE___________

 

MARITAL STATUS________________EDUCATION________________OCCUPATION_______________

 

1. CURRENT PROBLEM/CONCERNS_________________________________________________________

 

___________________________________________________________________________________________

 

2. OPERATIONS-WHEN/WHERE_____________________________________________________________

 

___________________________________________________________________________________________

 

3. HOSPITALIZATIONS-WHEN/WHERE______________________________________________________

 

___________________________________________________________________________________________

 

4. LIST MAJOR MEDICAL / EMOTIONAL ILLNESSES YOU HAVE HAD.

 

DIABETES_______HIGH BLOOD PRESSURE______CANCER________SEIZURES_________

HEPATITIS______LIVER______STOMACH______LUNGS______HEART______KIDNEY____

OTHER_____________________________________________________________________________

 

5. CURRENT MEDICATIONS: (NAME, DOSE, HOW OFTEN TAKEN)

 

___________________________________________________________________________________________

 

___________________________________________________________________________________________

 

6. DRUG ALLERGIES:_______________________________________________________________________

 

7. FAMILY HISTORY:

               

MOTHER _____________AGE ________HEALTH __________CAUSE OF DEATH ___________

                FATHER _____________ AGE _______ _HEALTH _________CAUSE OF DEATH ____________

 

LIST ANY DISEASES WHICH BLOOD RELATIVES HAVE:

               

DIABETES ________HIGH BLOOD PRESSURE _______CANCER _______SEIZERES ________

                HEPATITIS _______LIVER _______STOMACH ________LUNG ________THYROID _________

 

8. DO YOU USE OR HAVE YOU EVER USED:

               

ALCOHOL_______________ TABACCO_____________________DRUGS____________________

 

9. LIST ANY ADDITIONAL INFORMATION YOU FELL IS NECESSARY_________________________

 

___________________________________________________________________________________________

 

WOMEN ONLY

 

DATE OF LAST PERIOD __________________________ LIVE BIRTHS ____________________________

 

MISCARRIAGES __________LAST MAMMOGRAM ______________LAST PAP SMEAR ____________