Health History

  • PATIENT HEALTH HISTORY FORM

  • MILITARY SERVICE

  • DIFFICULTIES WITH ACTIVITIES OF DAILY LIVING?

  • WHO CURRENTLY LIVES IN YOUR HOUSEHOLD?

  • SURGICAL HISTORY

  • *CURRENT* MEDICAL CONDITIONS

  • *PAST* MEDICAL HISTORY


  • INTENTIONAL CHANGE
  • CONTAGIOUS DISEASE *PAST* HISTORY- IF APPLICABLE
  • TOBACCO USE*
  • CAFFEINE (soda, coffee, tea, etc)*
  • ALCOHOL INTAKE*
  • ALCOHOL FREQUENCY

  • ILLEGAL SUBSTANCE USE (including marijuana)*

  • DO FAMILY or FRIENDS WORRY ABOUT YOUR ALCOHOL OR SUBSTANCE USE
  • EXERCISE PER WEEK*

  • SEATBELT USE
  • NUTRITION

  • SLEEP*

  • TRAFFIC VIOLATION IN PAST 2 YEARS
  • PREVENTION MEASURES - Mark all that are completed and up to date*

  • HABITS

  • FAMILY HISTORY

  • REVIEW OF SYSTEMS

    (CHECK BOX IF RECENTLY or CURRENTLY EXPERIENCING)

  • GENERAL
  • PULMONARY
  • ENDOCRINE
  • SKIN
  • CARDIOVASCULAR

  • GENITOURINARY
  • NEUROLOGIC
  • MUSCLE/BONE/JOINT
  • EYES, EARS, NOSE, THROAT
  • GASTROINTESTINAL
  • MEN ONLY
  • WOMEN ONLY

  • PSYCOSOCIAL

  • By signing the form below I indicate that I have read and understood the Focus Family Medicine Patient Agreeement and agree to all its terms. 

    *** Thank you for becoming a patient at FOCUS Family Medicine***

    We look forward to serving you.

     

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