Prime Patient History Form

Patient History Form
Name
Birth date

MonthDayYear
Date
Marital Status
Occupation
Allergies to Medications, Latex or Dyes
List Allergies:
Type here
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Medications (Prescriptions, non-prescriptions, vitamins, and supplements)
List Medications:
Type here
Type here
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Surgeries/Hospitalizations/Serious Injuries (Please include the Year for each occurrence):
Type here Type here
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Immunizations (Please check if you have received):
Health Maintenance (Please check box if you have received):
Social History
Smoking
If Yes, How many packs per day?
Alcohol
If Yes, How many drinks per day? Per week?
Caffeine
If yes, How many drinks per day?
Recreational Drugs
If yes, describe:
Special Diet
If Yes, describe:
Regular Exercise
If Yes, describe:
Sexually Active
GYN History
Age of first mensus
Menopause
If Yes, What Age?
Regular Periods
Painful Periods
PMS
If Yes, Describe:
Abnormal Pap: - if Yes approximate date
If Yes, Approximate Date:
Pain with Intercourse:
Content with sex life:
OB History
Total Number of Pregnancies:
Full Term:
Pre Term:
Miscarriages:
Abortions:
Tubal:
Medical History (please check if positive):
ENT
CARDIOVASCULAR
PULMONARY
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
NEUROLOGICAL
HEMATOLOGICAL
ENDOCRINE
SKIN
PSYCH

Family History (please check all applicable boxes)

Social History