PATIENT MEDICAL HISTORY

Patient First Name

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Patient Last Name

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DATE OF BIRTH

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RACE

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LANGUAGE

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ETHNICITY

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FAMILY PHYSICIAN & DATE OF LAST VISIT:

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ADDITIONAL PHYSICIANS THAT YOU WOULD LIKE TO RECEIVE A COPY OF YOUR VISIT SUMMARY:

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PHARMACY NAME & PHONE

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REASON FOR TODAY'S APPOINTMENT:

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DRUG ALLERGIES

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MEDICATIONS WITH DOSAGE AND FREQUENCY (INCLUDING OVER THE COUNTER):

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10.

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DO YOU SMOKE?

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PACKS PER DAY

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YEARS SMOKED

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IF NO, HAVE YOU EVER SMOKED?

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PACKS PER DAY

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YEARS SMOKED

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YEAR QUIT

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DO YOU DRINK ALCOHOL?

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IF SO, HOW OFTEN?

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ALL PREVIOUS SURGERY INCLUDING ANY BY OUR OWN PHYSICIANS: APPROXIMATE DATE

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10.

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ANXIETY / DEPRESSION

FLU SHOT?

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DATE:

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PNEUMONIA SHOT?

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DATE:

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PERSONAL AND FAMILY HISTORY: (PLEASE INDICATE ALL THAT APPLY TO YOURSELF OR A FAMILY MEMBER)

ALZHEIMER'S DISEASE

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ANEMIA

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ANEURYSM

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Location:

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ANXIETY / DEPRESSION

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ASTHMA

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ARTHRITIS

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AUTOIMMUNE DISORDERS:

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Please specify:

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CLOTTING DISORDER

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Type:

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BRONCHITIS

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CANCER

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Type:

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CAROTID ARTERY DISEASE

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COPD/EMPHYSEMA

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CIRRHOSIS

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COLITIS

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CONGESTIVE HEART FAILURE (CHF)

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CROHN'S DISEASE

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DEEP VEIN THROMBOSIS (DVT)

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DIABETES: ~ INSULIN-DEPENDENT

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DIABETES: ~ NON INSULIN-DEPENDENT

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FAINTING SPELLS

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FIBROMYALGIA

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HEART~ ATRIAL FIBRILLATION

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HEART~ MURMUR

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HEART~ PALPITATIONS

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HEART ~ PACEMAKER / DEFIBRILLATOR

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HEART ~ VALVE DISEASE

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HEART ATTACK (MI)

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HEPATITIS

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HIGH CHOLESTEROL

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HYPERGLYCEMIA / HYPOGLYCEMIA

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HIGH BLOOD PRESSURE

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HYPERTHYROIDISM / HYPOTHYROIDISM

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KIDNEY - STONES

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KIDNEY - DISEASE

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MULTIPLE SCLEROSIS (MS)

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PARKINSON'S DISEASE

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PERIPHERAL VASCULAR DISEASE (PVD)

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PHLEBITIS

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PROSTATE DISEASE

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PULMONARY EMBOLISM (PE)

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RAYNAUD'S SYNDROME

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SEIZURE DISORDER

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THYROID DISEASE

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VARICOSE VEINS

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VERTIGO

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OTHER

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Please specify:

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