Patient History Form

Patient Name *

First Name Last Name

Patient Birth Date *

Month Day Year

Patient Gender *

Marital Status *

Race *

Occupation: *

The state of Texas maintains a free, confidential, secure, and voluntary vaccine registry called Immtrac. The registry is a very helpful resource to access your vaccination history. Do you consent to having SAMC report your vaccinations to Immtrac? *

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 (specify if maternal or paternal)	Kind
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

General Patient Information