hermosaplasticsurgery.com - Health History Form

Health History
Patient Name
Today's Date

MonthDayYear
Date
Age
Birthdate

MonthDayYear
Date
Date of last physical examination

MonthDayYear
Date
What is your reason for visit?
- Symptoms -

Check (V) conditions you currently have or have had in the past year.
GENERAL
MUSCLE/JOINT/BONE: Pain, weakness, numbness in
GENITO-URINARY
GASTROINTESTINAL
CARDIOVASCULAR
EYE, EAR, NOSE, THROAT
SKIN
MEN Only

Other
WOMEN Only

Other
Date of last menstrual period

MonthDayYear
Date
Date of last Pap Smear

MonthDayYear
Date
Have you had a mammogram?
Are you pregnant?
Number of children
- Conditions -
Check conditions you currently have or have had in the past year.
- Medications -
List medications you are currently taking
Pharmacy Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
- Allergies -
- Family History -

Relation

Check if, your blood relatives had any of the following diseases listed below:

- Hospitalizations -
Have you ever had a blood transfusion?
If yes, please give approximate dates
- Pregnancies -
- Health Habits -
Check which you use and how much you use.

Other
- Occupational -
Check if your work exposes you to:

Other
Occupation
To the best of my knowledge, the above information is complete and correct. I understand that it is my résponsibility to inform my doctor if I, or my minor child, ever have a change in health.
Signature of Patient, Parent, Guardian or Personal Representative
Date

MonthDayYear
Date
Name of Patient, Parent, Guardian or Personal Representative
Relationship to Patient
Should be Empty:

Health History