Patient Health History
Your Name
Please fill out this form completely.
PROBLEM LIST/PAST MEDICAL
Please check your diagnosed medical conditions, past and present:
Arthritis
Gout
High Blood Pressure
Paralysis
Stroke
Varicose Veins
Asthma
Heart Trouble
Kidney Trouble
Reflux
Thyroid Trouble
Other
Cancer
Hemorrhoids
Lumps and Bumps
Seizures
Tuberculosis
Other
Diabetes
Hepatitis
Migraines
Sleep Apnea
Ulcers
Other
Have you ever had a blood transfusion?
No
Yes when:
ALLERGY
Drug allergies and reactions:
FAMILY
Please check the biologic
family member
diagnosed with any of the following medical problems and/or conditions.
Medical Problem
Father
Mother
Sibling
Grandparent
Other
AIDS/HIV
Arthritis
Asthma
Cancer, Breast
Cancer, Family
Diabetes
Heart Trouble
High Blood Pressure
Kidney Trouble
Stroke
Ulcers
Other
SOCIAL
Have you ever smoked?
Never
Yes, but I quit
years ago, and smoked about
packs per day for
years.
Yes, I smoke
packs per day and have smoked for
years.
Do you drink alcohol?
No
Yes. Number of drinks per week
Do you or have you ever taken illicit drugs?
No
Yes. Substance:
Marital Status:
Married
Single
Widowed
Divorced
Separated
Living Status:
Alone
With
Employment Status:
Full Time
Part Time
Retired
Disabled
Unemployed
Other
Occupation:
MEDICATION
Please list all medications you are currently taking, including OTC medications and/or vitamin/herb supplements:
Medication Name
Dosage
Frequency
Reason
PREGNANCY / BIRTH
List all pregnancies (specify delivery type, miscarriages):
PAST SURGICAL
List all past operations, including dates: