MEDICAL HISTORY
 
LAST NAME: ____________FIRST NAME: _______________________DOB:_______

Medical Problems in SELF:

 
CONDITION Y(YES) N(NO) CONDITION Y (YES) N (NO)
High Blood Pressure     Thyroid disease    
Diabetes     Arthritis( Joint Pain)    
Heart Disease     Muscle aches    
Heart murmur     Anemia    
Pacemaker     Bleeding Problems    
High Cholesterol     Overweight    
Seizures     Joint replacement    
Stroke     Stress    
Acid Reflux     Anxiety    
Kidney Disease     Depression    
Liver Disease     Autoimmune diseases    
Asthma     Sexually Transmitted diseases ( please specify)    
Allergies     Cancer ( pl specify)    
Other lung disease     Sexual problems ( please specify)    
 Tuberculosis ( TB)      Other problems ( pl specify)    
 Pneumonia      Other problems (pl specify)    


CURRENT MEDICATIONS: ( please specify dose and frequency)
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________________________________________________________
________________________________________________________
________________________________________________________
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ALLERGIES:_______________________________________________
SURGERIES:______________________________________________
_________________________________________________________
SMOKING:Yes____ No____
If current smoker, specify duration and how many/day:________________
If Quit, specify date of quitting:____________________
ALCOHOL ( how many and how often):____________________________
ANY OTHER DRUG USE:______________________________________
EXERCISE: ( what type and how often)
SEXUALLY ACTIVE EVER: Yes___ NO___
USE OF CONDOMS: YES____ NO____
USE of other methods of Contraception: ( please specify):______________
( IUD, Tubal Ligation, Birthcontrol Pills, etc)


FAMILY HISTORY:
CONDITION Y(YES) N(NO) CONDITION Y (YES) N (NO)
High Blood Pressure     Thyroid disease    
Diabetes     Arthritis( Joint Pain)    
Heart Disease     Muscle aches    
Heart murmur     Anemia    
Pacemaker     Bleeding Problems    
High Cholesterol     Overweight    
Seizures     Joint replacement    
Stroke     Stress    
Acid Reflux     Anxiety    
Kidney Disease     Depression    
Liver Disease     Autoimmune diseases    
Asthma     Sexually Transmitted diseases ( please specify)    
Allergies     Cancer ( pl specify)    
Other lung disease     Other problems: Please specify    
 Tuberculosis ( TB)          
 Pneumonia          
 


IMMUNIZATION HISTORY:
Vaccine Yes No   Vaccine Yes No
tdAP       HPV shots    
Hepatitis A shots       Shingles    
Hepatitis B shots       Chicken pox    
Pneumonia shot       MMR    
Flu shot       Other: Pl specify    

PREVENTIVE SCREENING HISTORY:
Intervention Yes No Date
Last Full physical exam      
Last doctor’s visit and reason      
Last PAP ( females)      
Last mammogram ( females)      
Last Colonoscopy      
Last Bone density test      
Last Prostate test( Males)      
 
MENSTRUAL and CONCEPTION history(Females):
Last Menstrual Period: ( LMP)
Periods: Regular:_____  Irregular:_____
Heavy bleeding: Yes__ No__
Spotting: Yes___ No___
Number of pregnancies:___
Number of children____
Any miscarriages:____
Currently pregnant____  Currently nursing_____



 


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