Patient History Form

Patient Name *

First Name Last Name

Patient Birth Date *

Month Day Year

Patient Gender *

Marital Status *

Race *

Occupation: *

Would you like to be enrolled in the Texas Immunization Registry? *

YES NO

Personal Health History *

No

Yes

Date of Diagnosis (or Approximate)

Heart attack/angina

Heart failure

Stroke

High Blood Pressure

High Cholesterol

Asthma

COPD or Emphysema

Colitis or Bowel Disease

Liver Disease

Kidney Disease

Bone or Joint Disease

Diabetes

Thyroid Disease

Migraines

Allergies

Skin Disease

Cancer

Depression

Anxiety

Sexually Transmitted Disease

Other illnesses: *

Please list any drug allergies *

Please list any Operations and Dates of Each *

Please list your Current Medications *

Alcohol Consumption? (If YES, how many drinks/week?) *

Caffeine Consumption *

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day

Do you smoke? *

No 0-1 pack/day 1-2 packs/day 2+ packs/day

Have you ever smoked Tobacco? If so how long *

Have you ever had blood or plasma transfusion? If yes when *

Date of last diphtheria-tetanus booster *

WOMEN Date of last menstrual period. Do you use birth control? If yes what kind? Date and results of last pap smear *

Family Health History *

No

Yes

Family members

Kind