Crosspointe Medical History Form

Medical History
Please add your name and date to page 2 to ensure proper attrib
Name

First NameLast Name
Date

MonthDayYear
Date
Please List and Supply the Dates of:
Operations
Hospitalizations other than for surgery
Immunization history—have you had:
Hepatitis B?

YesNo
When?
Pneumovax immunization?

YesNo
When?
Flu immunization?

YesNo
When?
Tetanus immunization?

YesNo
When?
Other?

YesNo
When?
When was your last:
Pap Smear?

MonthDayYear
Date
Breast Exam?

MonthDayYear
Date
Colon Cancer Test?

MonthDayYear
Date
Mammogram?

MonthDayYear
Date
Cholesterol check?

MonthDayYear
Date
Prostate exam?

MonthDayYear
Date
Family History
Has any member of your family (including parents, grandparents, and siblings) ever had the following?
Illness
Which family members?
Age when diagnosed
Cancer (describe type)
Hypertension (high blood pressure)
Heart Disease
Diabetes
Strokes
Mental disease (anxiety, depression, etc.)
Drug or alcohol addiction
Glaucoma
Bleeding diseases
Other
Medications (Prescription, Over-the-counter, Vitamins, Herbs, etc.)
Drug Name & Dose
Drug Name & Dose
Drug Name & Dose
Prevention
Do you wear seat belts?

YesNo
If no, why not?
Do you wear a bike helmet?

YesNoN/A
Do you exercise regularly?

YesNo
If yes, type, duration and number of times per week?
Do you smoke?

YesNo
If yes, how many packs per day?
Do you drink alcoholic beverages?

YesNo
If yes, how much per week?
Do you drink coffee?

YesNo
If yes, how many cups per day?
Do you drink tea?

YesNo
If yes, how many cups per day?
If there is a gun in your home, do you keep it unloaded and out of children's reach?

YesNoN/A
Do you use drugs? (marijuana, cocaine, crack, etc.)

YesNo
If yes, explain:
Have you ever engaged in any activity which has put you at risk of getting AIDS?

YesNo
If yes, explain:
Do you wish to be tested for AIDS?

YesNo
Have you ever worked with chemicals, paints, asbestos, or other hazardous materials?

YesNo
If yes, explain:
Are you in a relationship in which you have been physically hurt (e.g., slapped, kicked, punched, bruised) by your partner?

YesNo
Do you ever feel afraid of your partner?

YesNoN/A
Do you have a "living will"?

YesNo
Do you have a donor card?

YesNo
Method of birth control?
This information is for use by your physician as part of your confidential medical record.
Should be Empty: