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.)?
If you have allergies to medications or other substances please list here
Have you ever had (Please check all that apply)
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
Eating following a diet
Alcohol Consumption
Caffeine Consumption
Do you smoke?
Do you vape?
Do you use recreational drugs?
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
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