Medical History
Last Name ________________________First Name___________________Initial______Age_____Acc#_______
Today's Date___/___/___ Birth Date___/___/___ Ref.Physician___________________Office (circle one) V H S
Please give us your medical history by completing Following:
Chief Complaint (CC) (What is your current complaint?):______________________________________________________
History of Present Illness (HPI) (To be completed by medical assistant or doctor):___________________________________
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Review of Systems (ROS) (check any symptom that you are currently experiencing)
Constitutional Symptoms: [] fever, [] chills, [] weight gain, [] weight loss, [] night sweats, [] fatigue, [] daytime somnolence, [] Failure to thrive
Organ symptoms:
Ophthalmologic: [] blurred vision, [] double vision, [] blindness, [] eye pain, [] itching, [] tearing, [] change in vision, [] field cuts, [] wears glasses
Otolaryngologic: [] hearing loss, [] ringing in ear(s), [] vertigo, [] ear pain, [] ear drainage, [] runny nose, [] nasal congestion, [] nose bleeds, [] post nasal drainage, [] sore throat, [] hoarseness, [] difficulty swallowing, [] snoring, [] headaches, [] dizziness, [] loss of sense of smell, [] throat swelling
Cardiovascular: [] chest pain, [] palpitations, [] shortness of breath on exertion, [] claudication, [] leg swelling, [] heart murmur, [] syncope
Respiratory: [] persistent cough, [] shortness of breath, [] sputum production, [] wheezing
Gastrointestinal: [] nausea, [] vomiting, [] diarrhea, [] abdominal pain, [] heartburn, [] indigestion, [] regurgitation, [] belching, [] vomiting blood, [] rectal bleeding, [] jaundice, [] constipation, [] tarry stools, [] swallowing difficulty
Genitourinary: [] frequency of urination, [] burning on urination, [] vaginal bleeding, [] vaginal drainage, [] urine retention, [] hesitancy/dribbling, [] irregular menstruation
Musculoskeletal: [] muscle or joint pain, [] back pain, [] neck pain, [] stiffness, [] weakness
Integumentary: [] rash, [] skin lesions/ulcers, [] itching, [] changes in nails, [] slow wound healing, [] change in skin color, [] paresthesias
Neurologic: [] numbness of limbs, [] weakness of limbs, [] headache, [] slurred speech, [] tremor, [] facial weakness, [] dizziness, [] loss of consciousness, [] loss of memory, [] seizures, [] unsteady gait
Psychiatric: [] change in mood, [] appetite change, [] behavior change, [] confusion, [] insomnia, [] anxiety, [] depression,
Endocrine: [] heat intolerance, [] cold intolerance, [] hair loss, [] unusual hair growth, [] excess appetite, [] excess hunger, [] excess thirst
Hematologic: [] bleeding, [] easy bruising, [] fatigue, [] swollen lymph glands, [] anemia, [] blood clots
Allergic/Immunologic: [] repetitive sneezing, [] itching in eyes, ears, nose or throat, [] food intolerance, [] congestion
Past Medical, Family, Social History (PFSH):
List your current medications including over-the-counter drugs such as aspirin, Tylenol, ibuprofen, nasal sprays, etc.
Medication and Dose Reason for Taking
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Drug Allergies Type of Reachtion
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Past Medical History:
Have you had or do you currently have any of the following medical conditions? (Check all that apply)
[] High blood pressure [] Irregular heart beat [] Coronary artery disease [] Myocardial infarction
[] Asthma [] Tuberculosis [] Emphysema [] Pneumonia
[] Colitis (IBS) [] Stomach/duodenal ulcer [] Esophageal reflux [] Hiatal hernia
[] Cirrhosis of the liver [] Hepatitis A, B, C [] AIDS [] Bladder problems
[] Kidney problems ]] Enlarged prostate [] Osteoporosis [] Arthritis
[] Skin cancer [] Cancer, site________ [] Anxiety [] Depression
[] Thyroid disorder [] Diabetes, Type I or II [] Infectious mononucleosis [] Lupus
[] Rheumatic fever [] Blood disorder [] Anemia [] Sickle cell anemia
[] Keloids [] Lyme disease [] Epilepsy [] Migraine headaches
[] Glaucoma [] Positive HIV [] Cataracts [] High cholesterol
[] Other_____________ [] Other____________ [] Other___________ [] Other___________
Past Surgical History:
Have you had any of the following operations? Please tell us the year it was performed.
Operation Year Operation Year Operation Year
Tonsils or Adenoids _____ Hernia repair _____ Gall bladder _____
Appendix _____ Hysterectomy _____ Thyroid surgery _____
D & C _____ Coronary bypass _____ Ear surgery _____
Sinus surgery _____ Cataracts _____ Nasal surgery _____
Other _____ Other _____ Other _____
Family History:
Do any of the following diseases tent to run in your family? (Circle all that apply): Heart disease, Cancer, Tuberculosis, High blood pressure, Diabetes, Deafness, Autoimmune Disease, Bleeding disorder, Other__________________________________
If Living If Deceased
Age Current Medical Problems Age at Death Cause of Death
Biologic Father ___ _____________________________ ___ _____________________________________
Biologic Mother ___ _____________________________ ___ _____________________________________
Brothers/Sisters ___ _____________________________ ___ ____________________________________
___ _____________________________ ___ ____________________________________
___ _____________________________ ___ ____________________________________
Social History:
Tobacco:
Have you ever smoked? Y N Number of years you smoked______ Number of packs per day_____
Do you currently smoke? Y N When did you stop smoking?_______
Alcohol:
Do you drink beer, hard liquor, wine (circle all that apply)? Number of years_____. How much do you drink?_____cans/ounces/glasses per day/week (circle which ever applies)
Caffeine:
Please indicate the number of ounces per day_____. Coffee, tea, caffeinated soft drinks (circle any that apply)
Work History:
Please tell us the type of work you have done, where and when you were employed:
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Pregnancy/Breast feeding/Premedication:
Are you now pregnant? Y N If so, how many weeks?______ Are you currently breast feeding? Y N
Do you require premedication with antibiotics before a dental or surgical procedure? Y N If yes, please tell us the reason_________________________________________________________________________________________________