Patient Medical History Form

General Medical Information
Patient Gender*
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Primary Care Provider Name, Practice Name:*
Ex: 62"
Patient Height (inches)*
Ex: 62"
Patient Weight (lbs)*
Ex: 120.5
Patient E-Mail*
example@example.com
Reason for seeing the provider today:*
Date of Last Physical Exam:*
Please indicate if LABS were done at this exam and supply results at your appointment
Do you have any DRUG ALLERGIES, please list:*
Please indicate what symptom is with medication
Patient Medical History
Have you ever had (Please check all that apply)*

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaOther
Other illnesses:
please describe any symptoms issue you may "think you have"
If female, date of Last Mentrual Cycle or onset of Menopause:
Form of Contraception if sexually active:
Please list your Current Medications, DOSAGE, including nutritional supplements *
Please list any Operations and Dates of Each, please include childbirth & cosmetic*
Healthy & Unhealthy Habits
Exercise*

Never1-2 days3-4 days5+ days
Eating following a diet*

I AVOID certain foodsI have a strict dietI don't have a diet planGluten FreeVegetarianKeto
Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/dayI drink coffee as my caffeineI drink Tea or Soda as my daily caffeineI drink energy drinks daily
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Should be Empty:

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General Medical Information

Patient Medical History

Healthy & Unhealthy Habits