Patient Medical History Form

SouthPointe Plaza

1901 E 32nd St Ste 20

Joplin MO

(417) 781-2046

www.apclinic.net
Patient Medical History
Date*

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Patient Birth Date*

MonthDayYear
Do you have any allergies to medications or other substances (pet, food, etc.)?*

NoYes
If you have allergies to medications or other substances please list here
Have you ever had (Please check all that apply)

ADD/ADHDAlcoholismAllergiesAnaphylaxisAnemiaAnxietyArthritisArtificial Heart ValvesArtificial JointAsthmaBack ProblemsBipolar DisorderBlood TransfusionBruises EasilyCancerCerebral PalsyCholesterol DisorderChrohn's DiseaseChronic CoughChronic FatigueChronic SinusitisCirculatory ProblemsCongenital Heart DefectCOVID-19Digestive ProblemsGoutDepressionDiabetesDizzinessDrug AddictionEmotional DisorderEmphysema/COPDEpilepsy SeizuresFainting SpellsFever BlistersFibromyalgiaGall Bladder ProblemsGallstonesGlaucomaHeadachesHeart AttackHeart DiseaseHeart MurmurHeart PacemakerHemophiliaHepatitisHerpesHigh Blood PressureHIV/AIDSKidney DiseaseLiver DiseaseLow Blood PressureLung DiseaseMedical MarijuanaMitral Valve ProlapseMultiple SclerosisOsteoporosisPsychiatric CareUlcerative ColitisUlcer DiseaseNeurological DisordersRheumatic FeverScarlet FeverSeizuresShinglesShortness of BreathSkin RashSleep ApneaUse a C-PAP machineSmokingSnoringStrokeSwelling Feet/AnklesThyroid ProblemsTuberculosisUlcerative ColitisVenereal 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

Never1-2 days3-4 days5+ days
Eating following a diet

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

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Do you vape?

NoYes
Do you use recreational drugs?

NoYes
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*

Clear
Patient Signature
Patient Name*

First NameMiddle NameLast Name
Legal Guardian (if applicable)

First NameLast Name
Should be Empty:

Patient Medical History

Family Medical History

Health Habits

Signature of Patient or Legal Guardian