Crosspointe Medical History Form

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

First Name Last Name
Date

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

Yes No
When?
Pneumovax immunization?

Yes No
When?
Flu immunization?

Yes No
When?
Tetanus immunization?

Yes No
When?
Other?

Yes No
When?
When was your last:
Pap Smear?

Month Day Year
Date
Breast Exam?

Month Day Year
Date
Colon Cancer Test?

Month Day Year
Date
Mammogram?

Month Day Year
Date
Cholesterol check?

Month Day Year
Date
Prostate exam?

Month Day Year
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?

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

Yes No N/A
Do you exercise regularly?

Yes No
If yes, type, duration and number of times per week?
Do you smoke?

Yes No
If yes, how many packs per day?
Do you drink alcoholic beverages?

Yes No
If yes, how much per week?
Do you drink coffee?

Yes No
If yes, how many cups per day?
Do you drink tea?

Yes No
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?

Yes No N/A
Do you use drugs? (marijuana, cocaine, crack, etc.)

Yes No
If yes, explain:
Have you ever engaged in any activity which has put you at risk of getting AIDS?

Yes No
If yes, explain:
Do you wish to be tested for AIDS?

Yes No
Have you ever worked with chemicals, paints, asbestos, or other hazardous materials?

Yes No
If yes, explain:
Are you in a relationship in which you have been physically hurt (e.g., slapped, kicked, punched, bruised) by your partner?

Yes No
Do you ever feel afraid of your partner?

Yes No N/A
Do you have a "living will"?

Yes No
Do you have a donor card?

Yes No
Method of birth control?
This information is for use by your physician as part of your confidential medical record.
Should be Empty: