• Crosspointe Medical History Form

    Crosspointe Medical History Form
  • Date
     - -
  • Date of Birth
     - -
  • Sex
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Marital Status
  • Allergies to Medications, X-Ray Dyes, or Other Substances

  • Past Medical History and Review of Systems

    Please check off if you have had any problems with or are presently experiencing any of the following:

  • Gynecologic and Obstetric History

  • Prolonged or abnormal bleeding
  • Leakage of urine
  • Pelvic pain
  • Abnormal discharge
  • History of abnormal Pap smear

  • This information is for use by your physician as part of your confidential medical record.

  • Medical History

  • Please add your name and date to page 2 to ensure proper attrib

  • Date
     - -

  • Please List and Supply the Dates of:

  • Immunization history—have you had:

  • Hepatitis B?
  • Pneumovax immunization?
  • Flu immunization?
  • Tetanus immunization?
  • Other?

  • When was your last:

  • Pap Smear?
     - -
  • Breast Exam?
     - -
  • Colon Cancer Test?
     - -
  • Mammogram?
     - -
  • Cholesterol check?
     - -
  • Prostate exam?
     - -

  • 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?
  • Do you wear a bike helmet?
  • Do you exercise regularly?
  • Do you smoke?
  • Do you drink alcoholic beverages?
  • Do you drink coffee?
  • Do you drink tea?
  • If there is a gun in your home, do you keep it unloaded and out of children's reach?
  • Do you use drugs? (marijuana, cocaine, crack, etc.)
  • Have you ever engaged in any activity which has put you at risk of getting AIDS?
  • Do you wish to be tested for AIDS?
  • Have you ever worked with chemicals, paints, asbestos, or other hazardous materials?
  • Are you in a relationship in which you have been physically hurt (e.g., slapped, kicked, punched, bruised) by your partner?
  • Do you ever feel afraid of your partner?
  • Do you have a "living will"?
  • Do you have a donor card?

  • This information is for use by your physician as part of your confidential medical record.

  • Should be Empty: