YOUR MEDICAL HISTORY


Dr. Smith would like to know your past medical history in order to understand how he can help you. The information you give on this form will be kept confidential, for our files in this office only. The information will not be released to anyone else, unless you request the release in writing.

NAME ____________________________________________________ DATE ___________

REFERRED BY ______________________________________________________________

1. When was your last medical checkup? _______________________________________

Why are you here to see Dr. _____________ today?

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2. Have you been hospitalized or had surgery in your lifetime? Yes _________ No ______

FOR WHAT? WHEN?

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MONTH YEAR
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MONTH YEAR
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MONTH YEAR
3. Have you had any other illnesses or injuries during your lifetime?

WHAT ILLNESS? WHEN?

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MONTH YEAR
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MONTH YEAR
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MONTH YEAR

4. Medications ______________________________________________________________

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5. Allergies _________________________________________________________________

6. REVIEW OF SYSTEMS: ( Circle below only those conditions that you know you have had).

EENT: eye disease, glaucoma, glasses, sinus trouble, hay fever, nose bleeds, ringing in ears, deafness, postnasal drip, broken eardrum

LUNGS: coughing blood, persistent cough, shortness of breath, emphysema, asthma, 
frequent chest infections, pneumonia, pleurisy

HEART: heart trouble, murmurs, enlarged heart, irregular heart, fluttering, chest pains, severe swelling, heart attack, high blood pressure

INTESTINES: difficulty swallowing, indigestion, ulcer, liver disease, cirrhosis, hepatitis, 
gallbladder trouble, vomiting blood, black bowel movements, hemorrhoids, 
blood in bowel movements, yellow jaundice

KIDNEYS: painful urination, frequent urination, waking at night to urinate, pus, blood, stones, albumin, loss of control with cough or laugh, (MALE PATIENTS) prostate trouble, impotency, ejaculation problems

NERVOUS SYSTEM: headaches, convulsions, epilepsy, head injury, fainting, paralysis, double vision, blurred vision, staggering, unconsciousness, persistent numbness

Do you take Aspirin? Yes _______ No ________

(Female Patients) Menstrual periods began at age ____, ceased at age ____, occur every ____ days, last ____ days. Pain with periods? ____ Number of pregnancies ____ Number of births ____.

7. SOCIAL HISTORY: Do you have regular exercise habits? Yes____ No ____. Do you sleep regularly? Yes____ No ____. Eat well-balanced meals? Yes ____ No ____.

A. Do you smoke? _____ How Long? _____ How Much? _______________________

B. Have you ever smoked? ____ How Long? _____ How Much? _________________

C. Do you drink? _____ How Long? __________ How Much? ___________________

8. FAMILY HISTORY:

Mother living? _____ age _____ (or) died at age _____ Cause ___________________

Father living? _____ age _____ (or) died at age _____ Cause ___________________

Brothers living? _____ # deceased _____ age at death ____ Cause _______________

Sisters living? _____ # deceased _____ age at death ____ Cause _______________

CIRCLE ONLY THOSE CONDITIONS ANYONE IN YOUR FAMILY HAS HAD: Heart trouble ,diabetes, gout, tuberculosis, cancer, high blood pressure, glaucoma, kidney disease.

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