Medical History Form

Patient Medical History
Please answer these questions as completely and honestly as possible, so we can help you be as healthy as you can be.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Information
Name

PrefixFirst NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Occupation
Last Grade Completed in School:
Marital Status
Email
example@example.com
Primary Phone Number

Area CodePhone Number
Can we text you at this number?
Secondary Phone Number

Area CodePhone Number
Can we text you at this number?
Medical Information

Family Medical History

Please list any hospitalizations or surgeries:

Additional Info for Women Only:
Are you pregnant?
Are you planning a pregnancy?
Date of your last mammogram:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of your last pap smear:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Personal Medical History

Check all conditions that apply to you:

Rows
Headaches
Shortness of Breath
Heart Palpitations
Chest Pain
Dizziness/Fainting
Peripheral Vascular Disease
Allergies/hay fever
Asthma
Bronchitis
Pneumonia
Ulcer
GI Disorder
Early Morning Awakening
Daytime Drowsiness
Difficulty Falling Asleep
Lactose Intolerance
Gallbladder Disease
Renal Disease
Prostate Disease
Bowel Irregularity
Incontinence
Sexual/Menstrual Dysfunction
Veneral Disease
Frequent Infections
Hepatitis
Anemia
Arthritis
Osteoarthritis
Hearing Loss
Problems with reading or vision loss
Snoring
Nervousness
Depression
Gout
Scarlet Fever
Chronic Rashes
Rheumatic Fever
AIDS/HIV
Past Stroke
Past Heart Attack
Diabetes

Date of last tetanus shot:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last flu shot:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last pneumonia vaccine:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you smoke?
How long have you smoked?
How many packs per day?
Are you interested in quitting?
Do you drink?
How many days per week?
Type:
How many drinks at a time?
What exercise do you enjoy?
How often do you exercise?
What prevents you from exercising?
Regular Method of Transportation:

Other
Other health questions/concerns:
Additional Info for Patients with Diabetes:
Have you been told by a doctor that you have diabetes?
If yes, when?
Please list all diabetes medications that you are taking:
Do you feel that your diabetes medicines are working properly?
What was your most recent A1c level?
Insert Number or "Don't Know"
Check any of these tools that you currently have for managing your diabetes:
Would you like to learn more about managing your diabetes?

In the past 12 months, have you seen or been to:

Rows	Number of Visits	Reason
Primary Doctor
Emergency Room
Overnight Hospital Stay
Eye Doctor
Foot Doctor
Diabetes Education Class or Counseling

What was your most recent fasting blood sugar at home?
Insert number or "Don't Know"
When do you check your blood sugar? Check all that apply:

Other
Do you have strips to check your blood sugar?
Would you like to learn more about checking your blood sugar?
When your blood sugar is low, what do you do?
What health concerns would you like to discuss today?
What type of eating plan are you on?

Other
What's the hardest thing about having diabetes?
Should be Empty:

Patient Medical History