Patient Medical History Form

SouthPointe Plaza

1901 E 32nd St Ste 20

Joplin MO

(417) 781-2046

www.apclinic.net
Patient Medical History
Date *

Month Day Year
Date
Patient Name *

First Name Middle Name Last Name
Patient Birth Date *

Month Day Year
Patient Gender *
Patient E-Mail
example@example.com
Reason for seeing the practitioner: *
Do you have any allergies to medications or other substances (pet, food, etc.)? *

No Yes
If you have allergies to medications or other substances please list here
Have you ever had (Please check all that apply)

ADD/ADHD Alcoholism Allergies Anaphylaxis Anemia Anxiety Arthritis Artificial Heart Valves Artificial Joint Asthma Back Problems Bipolar Disorder Blood Transfusion Bruises Easily Cancer Cerebral Palsy Cholesterol Disorder Chrohn's Disease Chronic Cough Chronic Fatigue Chronic Sinusitis Circulatory Problems Congenital Heart Defect COVID-19 Digestive Problems Gout Depression Diabetes Dizziness Drug Addiction Emotional Disorder Emphysema/COPD Epilepsy Seizures Fainting Spells Fever Blisters Fibromyalgia Gall Bladder Problems Gallstones Glaucoma Headaches Heart Attack Heart Disease Heart Murmur Heart Pacemaker Hemophilia Hepatitis Herpes High Blood Pressure HIV/AIDS Kidney Disease Liver Disease Low Blood Pressure Lung Disease Medical Marijuana Mitral Valve Prolapse Multiple Sclerosis Osteoporosis Psychiatric Care Ulcerative Colitis Ulcer Disease Neurological Disorders Rheumatic Fever Scarlet Fever Seizures Shingles Shortness of Breath Skin Rash Sleep Apnea Use a C-PAP machine Smoking Snoring Stroke Swelling Feet/Ankles Thyroid Problems Tuberculosis Ulcerative Colitis Venereal Disease
Other illnesses:
Please list any hospitalizations and dates of each
Please list any surgeries and dates of each
Please list your Current Medications
Family Medical History
Please list any major conditions that your immediate family members have had
Mother
If deceased, at what age
Father
If deceased, at what age
Sibling 1
If deceased, at what age
Sibling 2
If deceased, at what age
Sibling 3
If deceased, at what age
Other
If deceased, at what age
Health Habits
Exercise

Never 1-2 days 3-4 days 5+ days
Eating following a diet

I have a loose diet I have a strict diet I don't have a diet plan
Alcohol Consumption

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day
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
Do you vape?

No Yes
Do you use recreational drugs?

No Yes
Include other comments regarding your Medical History
Signature of Patient or Legal Guardian

By signing this form I attest to the accuracy of the information provided to the best of my knowledge and hereby agree and give my consent to the practitioner to furnish medical care and treatment considered necessary and proper in diagnosing or treating my physical and/or mental condition.
Patient Signature *

Patient Signature Clear
Patient Name *

First Name Middle Name Last Name
Legal Guardian (if applicable)

First Name Last Name
Should be Empty:

Patient Medical History

Family Medical History

Health Habits

Signature of Patient or Legal Guardian