Prime Patient History Form

Patient History Form
Name
Birth date

MonthDayYear
Date
Marital Status
Occupation
Allergies to Medications, Latex or Dyes

NoneYes (please list below)
List Allergies:
Type here
Type here
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Medications (Prescriptions, non-prescriptions, vitamins, and supplements)

NoneYes (please list below)
List Medications:
Type here
Type here
Type here
Type here
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Surgeries/Hospitalizations/Serious Injuries (Please include the Year for each occurrence):
Type here Type here
Type here Type here
Type here Type here
Immunizations (Please check if you have received):

Hepatitis B SeriesGardasil SeriesChicken Pox Immunization or diseaseRecent Pneumonia VaccineRecent Flu VaccinePositive TB Screening
Health Maintenance (Please check box if you have received):

ColonoscopyMammogramPap SmearBone DensityEye ExamPhysical Exam
Social History
Smoking

NoYes
If Yes, How many packs per day?
Alcohol

NoYes
If Yes, How many drinks per day? Per week?
Caffeine

NoYes
If yes, How many drinks per day?
Recreational Drugs

NoYes
If yes, describe:
Special Diet

NoYes
If Yes, describe:
Regular Exercise

NoYes
If Yes, describe:
Sexually Active

NoYes, with MenYes, with WomenYes, with Both
GYN History
Age of first mensus
Menopause

NoYes
If Yes, What Age?
Regular Periods

NoYes
Painful Periods

NoYes
PMS

NoYes
If Yes, Describe:
Abnormal Pap: - if Yes approximate date

NoYes
If Yes, Approximate Date:
Pain with Intercourse:

NoYes
Content with sex life:

NoYes
OB History
Total Number of Pregnancies:
Full Term:
Pre Term:
Miscarriages:
Abortions:
Tubal:
Medical History (please check if positive):
ENT

Eye ProblemsSinus ProblemsHearing Loss
CARDIOVASCULAR

Abnormal EKGChest PainHeart AttackHeart DiseaseHigh Blood PressureHigh CholesterolStrokePeripheral Vascular Disease
PULMONARY

AsthmaEmphysema/COPDShortness of BreathSleep Apnea
GASTROINTESTINAL

Acid RefluxConstipationDiarrheaIrritable BowelGall Bladder DiseaseHerniaLiver Disease
GENITOURINARY

Urinary InfectionsKidney Disease/StonesErectile DysfuntionSTDUrinary Incontinence
MUSCULOSKELETAL

Arthritis/OsteoArthritis/RheumatoidGoutNeck/Spinal Problems
NEUROLOGICAL

ConcussionHeadachesMigrainesEpilepsy/Seizures
HEMATOLOGICAL

AnemiaBleeding DisordersBlood ClotsCancerSickle Cell Disease
ENDOCRINE

DiabetesThyroid DiseasePancreatitis
SKIN

PsoriasisSkin DisordersMelanoma
PSYCH

ADD/ADHDAnxietyDepressionMemory LossOCDSuicidal Thoughts/Attempts

Family History (please check all applicable boxes)

	Father	Mother	Sibling	Child	Maternal G-Mother	Maternal G-Father	Paternal G-Mother	Paternal G-Father
Asthma
Bleeding Disorders
Breast Cancer
Colon Cancer
Depression Anxiety
Diabetes
Drug/Alcohol Addiction
Heart Disease
High Blood Pressue
High Cholesterol
Kidney Disease
Leukemia
Liver Disease
Lung Cancer
Osteoporosis
Ovarian Cancer
Pancreatic Cancer
Rheumatoid Arthritis
Stroke
Thyroid Disease

Should be Empty:

Social History

GYN History

OB History

Medical History (please check if positive):