Medical History Form

Medical History Form
Full Legal Name*
Preferred Name
Date of Birth*

MonthDayYear
Gender
Pronouns
Other medical providers involved in my care
What would you like to discuss today? Please limit to two items.*
Current Medications

(Please note, we do not routinely prescribe most long-term, controlled medications.)

*Please bring your medication bottles to your office visit.

Rows	Medication	Dose	Times Per Day
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10

Preferred Pharmacy*
Drug Allergies

Rows	Medication	Type of Reaction
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Surgical History

Rows	Surgery	Year Performed
Surgery 1
Surgery 2
Surgery 3
Surgery 4

Hospitalizations

Rows	Illness or Injury	Date(s)
Hospitalization 1
Hospitalization 2
Hospitalization 3
Hospitalization 4

Personal Medical History

Have you been diagnosed with any of the following conditions?
Breast CancerColon CancerLung CancerProstate CancerSkin CancerOtherNone of the Above
Other Cancer
Gastroesophageal Reflux DiseaseHepatitisIBSPeptic UlcersOtherNone of the Above
Other Gastrointestinal
Hepatitis Type*
Abnormal Pap SmearOvarian CystOtherNone of the Above
Other Gynecology
Abdominal Aortic AneurysmAtrial FibrillationCongestive Heart FailureCoronary Artery DiseaseDeep Vein Thrombosis/Pulmonary EmbolismHeart AttackHeart Valve ConditionHyperlipidemiaHypertensionPeripheral Vascular DiseaseOtherNone of the Above
Other Heart/Vessels
Benign Prostate HypertrophyChronic Kidney DiseaseElevated PSAErectile DysfunctionKidney StonesUrinary IncontinenceOtherNone of the Above
Other Kidney/Bladder
ADHDAlcohol/Substance Use DisorderAnxietyDepressionMigraine/HeadacheNeuropathyStroke/TIAOtherNone of the Above
Other Mental Health/Neurologic
AnemiaDiabetes/Prediabetes/Gestational DiabetesEating DisorderThyroid DisorderOtherNone of the Above
Other Metabolic/Nutrition
FibromyalgiaOsteoarthritisOsteopenia/OsteoporosisRheumatoid ArthritisOtherNone of the Above
Other Musculoskeletal
AllergiesAsthmaChronic Obstructive Pulmonary DiseaseSleep ApneaOtherNone of the Above
Other Respiratory
Social History
Occupation*
SingleMarriedDomestic PartnershipDivorcedWidowed
YesNo
If yes, what are their dates of birth?*
Who do you live with?*
Do you feel safe at home?*
YesNo
Type/frequency of physical activity*
YesNo
If yes, how many per day?*
Tobacco Use
FormerCurrentNever
CigarettesVapeSmokeless tobaccoCigars or pipes
How much tobacco did you formerly use per day?*
Age when you started using tobacco*
Year quit*
CigarettesVapeSmokeless tobaccoCigars or pipes
How much tobacco do you currently use per day?*
Age when you started using tobacco*
YesNo
Alcohol Use
FormerCurrentNever
How many drinks did you formerly have per day?*
Year quit*
How many drinks do you currently have per day?*
Cannabis Use
FormerCurrentNever
What type did you formerly use?*
How often did you formerly use cannabis?*
Last use of cannabis*
What type do you currently use?*
How often do you currently use cannabis?*
Illicit Drug Use
FormerCurrentNever
What type of illicit drugs did you formerly use?*
How often did you formerly use illicit drugs?*
Last use of illicit drugs*
What type of illicit drugs do you currently do?*
How often do you currently do illicit drugs?*
Family History

Rows	Family member(s)	Age of onset	If deceased, age of death
Alcohol/Substance Use Disorder
Bleeding/Clotting Disorder
Cancer
Dementia
Diabetes
Gastrointestinal Disease
Growth/Development Disorder
Heart Disease/Heart Attack
High Cholesterol
Hypertension
Liver Disease
Migraine Headache
Osteoporosis
Respiratory Disease
Seizure Disorder
Stroke
Thyroid Disorder
Other

Review of Systems

Check any of the following concerns or symptoms you have experienced in the past month.
Appetite ChangeChange in Heat or Cold ToleranceFever or ChillsNight Sweats or Hot FlashesRecurrent InfectionsSwollen GlandsUnusual FatigueWeight LossWeight GainOtherNone of the Above
Other
Weight Loss*
Weight Gain*
AnxietyConcentration or Memory IssuesConcern About Substance UseDepressed MoodMarital, Family or Work IssuesSleep ProblemsSuicidal ThoughtsOtherNone of the Above
Other Mental Health
Back or Neck PainPainful or Stiff JointsRed or Swollen JointsOtherNone of the Above
Other Musculoskeletal
Changes in Skin or MoleNail ChangeRash or HivesUnusual Hair LossOtherNone of the Above
Other Skin
Change in VisionContact LensesEye PainOtherNone of the Above
Other Eyes
Bleeding GumsEaracheEnvironmental AllergyHearing LossHoarsenessNeck SwellingNose BleedsRinging in EarsSinus PainOtherNone of the Above
Other Ears/Nose/Throat
BreastfeedingLumpNipple DischargePainRash of BreastOtherNone of the Above
Other Breasts
Cough up BloodPersistent CoughShortness of BreathWheezingOtherNone of the Above
Other Lungs
Chest Discomfort or PainExcessive Bleeding or BruisingIrregular Heart BeatRacing or Fluttering HeartSwollen Feet or AnklesVaricose VeinsOtherNone of the Above
Other Heart
Abdominal PainBloody or Black StoolsChange in StoolsConstipationDiarrheaDifficult SwallowingFood AllergyHeartburnHemorrhoidsVomiting or NauseaOtherNone of the Above
Other Gastrointestinal
Blood in UrineChange in Urinary StreamFrequent UrinationHeavy Menstrual BleedingIrregular Menstrual PeriodsLeaking UrinePain or Burning with UrinationPelvic PainPMSSexual ConcernsUp at Night to UrinateVaginal or Penile DischargeOtherNone of the Above
Other Genital/Urinary
Coordination ProblemsDifficulty in SpeakingDizzinessFainting SpellsFrequent HeadachesMuscle WeaknessNumbness or TinglingOtherNone of the Above
Other Neurologic
Signature*
Today's Date*

MonthDayYear
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Medical History Form

Current Medications

Drug Allergies

Surgical History

Hospitalizations

Personal Medical History

Social History

Tobacco Use

Alcohol Use

Cannabis Use

Illicit Drug Use

Family History

Review of Systems