MEDICAL HISTORY Identification data Name: Today's
date: Email
address: celll
phone Age: Date
of birth: Male/female
(circle one) Height: Weight: Current health
problems (please list the
main things that are bothering you at the present): Family history - Please include information regarding any
diseases which run in your family, including alcoholism, allergies, arthritis,
asthma, cancer, diabetes, epilepsy, frequent colds, infections, gout, hay
fever, heart problems, insanity,
nervous breakdown, obesity, paralysis, pleurisy, pneumonia, skin affections, thyroid problems, tuberculosis, ulcers, stomach
problems, diabetes, or anything else. Age Age at death Ailments Father: Mother: Brothers: Sisters: Maternal Grandfather: Grandmother: Aunts/uncles: Paternal Grandfather: Grandmother: Aunts/uncles: Medications:
(please bring with you all
prescribed, over the counter, vitamins, herbals medicines, and any other
therapeutic substance you are currently using.
Don't forget to include aspirin, birth control, thyroid, hormones,
cortisone, prednisone, 'recreational drugs', diet or pep pills, sleeping pills,
tranquilizers, creams, homeopathics, etc.
You may list them here if you wish. Past medications: (please list all such products you have used in the past and what
effect they had on you. include WHEN
and HOW LONG you used these products.) Recent Immunizations: Include smallpox, mumps, measles, rubella
(German measles), hemophilus, tetanus, rabies, typhoid, tuberculosis, oral
polio, injected polio, cholera, diphtheria, pertussis (whooping cough), etc. Immunization Date Reaction Birth history: city/state of birth: home/hospital/other (circle one) Health of mother
during pregnancy with you: Complications of
your mother's labor and delivery: Birth wt: Chemical exposure:
Please list exposure you have had to chemicals, pesticides, toxins,
etc. How did this exposure affect you? Female history : number of pregnancies: number
of births: number of miscarriages: number of abortions: other
pregnancy related problems: menstrual periods: age when had first period: date of last period: pre
menstrual symptoms (please describe): duration
of period: how long from the start of one period to the next: amount
of flow: color of flow: symptoms
during period: Social history section Marital status: Education: Occupation: Religious
Preference: Spouses Name: Health of spouse: Spouse's occupation: Children's names age health
problems Tobacco use (when
and for how long): Alcohol use (when
and for how long): Exercise (how much,
how often, what kind): Leisure activities /
hobbies Past medical history section Hospitalizations
and/or surgeries Date Reason why / after effects_______ Review of Systems section Please circle those
areas in which you currently have a problem: Constitutional Weight gain, weight loss, fatigue,
sleep, other Head Headaches, migraine, trauma history,
dizziness, vertigo, other Eyes Visual loss, color blindness, double
vision, blurred vision, injury, inflammation, glasses, other Ears Deafness, ringing ears, discharge,
pain, other Nose Discharge, sinusitis, obstruction,
bleeding, change in ability to smell, other Throat Hoarseness, sore throats, tonsillitis,
voice changes, other Mouth Soreness of mouth or tongue, canker
sores, tooth problems Cardiovascular Palpitations, fast heartbeat,
irregular heartbeat, chest pain, shortness of breath, swelling of extremities,
high blood pressure, heart disease, high cholesterol, other Respiratory Chest pain, cough, shortness of
breath, wheezing, night sweats, coughing up blood, exposure to tuberculosis,
other Gastrointestinal Appetite changes, pain, nausea,
burping, gas, vomiting, jaundice, hemorrhoids, bleeding, constipation,
diarrhea, ulcers, other Genitourinary Increased/decreased urine, frequency,
pain, stones, sexual dysfunction, history of venereal disease, prostate
problems, genital warts, herpes, other Musculoskeletal arthritis, muscle/joint pain,
swelling, stiffness, disabilities, weakness, night cramps, other Skin Pigmentation changes, perspiration,
eruptions, acne, itching, bruising, bleeding, problems with nails (clubbing,
splitting, spots, brittleness), warts, other Breast Swelling, lumps, pain, nursing, other Neurological Convulsions, paralysis,
incoordination, pain, loss of touch, strokes, fainting, learning disability,
other Psychiatric Nervous breakdowns, depression,
alcoholism, drug addiction, psychiatric diagnosis, hallucinations, suicidal
thoughts, other Endocrine Known glandular problem (thyroid,
adrenal, pituitary, etc.), growth problems, weight problems, diabetes, goiter,
hunger/thirst problems, baldness, hypoglycemia, other Hematologic Anemia, bleeding, other Lymph glands Swelling, pain, other Allergic/immunologic Allergies, hives, eczema, hay fever,
asthma, migraine, other Pain, describe your
pain, including location, intensity, things that make it better or worse. Other Please list any other health problems
which you have: Please list any other significant
health problems which you have had in the past: |