Medical History (Confidential)

GENERAL INFORMATION
Patient Name Patient Name First Last
Date Date / MM / DD YYYY
Gender born as

Gender born as Female Male
Gender Identity (if different from above)
Weight
Age
Date of Birth Date of Birth / MM / DD YYYY
Marital Status
Phone Number Phone Number - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
e-mail address
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
P.O. Box Address if applicable
Occupation and Employer
Insurance Provider
Who may we thank for referring you? How did you hear about us?
EMERGENCY CONTACT INFORMATION
Name Name First Last
Relationship
Phone Phone - ### - ### ####
MAJOR COMPLAINT
What is the primary reason for this visit?
This condition is due to?
Date of injury/ illness? Date of injury/ illness? / MM / DD YYYY
When did your symptoms begin?
How did your symptoms develop:

How did your symptoms develop: Suddenly Gradually Other
How long do symptoms last?
Is there a pattern to when your symptoms occur?

Is there a pattern to when your symptoms occur? In the morning In the evening All day Occasionally Intermittently Constantly During sleep Upon waking Other
if Other was checked, specify here:
What initiates your symptoms?
What makes them worse?
What makes them better?
Have you received treatment for this complaint?
If Yes, what was done?
Did it help?
What has prevented you from getting well in the past?
Do you have specific questions you would like to discuss in this visit?
FAMILY HISTORY
Check all which have occurred in any of your blood relatives:

Check all which have occurred in any of your blood relatives: Alcoholism Allergy Bleed easily Cancer Death Diabetes Epilepsy Heart Disease High Blood Pressure Kidney Disease Mental Illness Obesity Stroke
List any other family ailments not listed above:
Other illness(es) which have occurred in any of your blood relatives:
PERSONAL HISTORY
How would you describe your health as a child?
Check illnesses or conditions you have or had in the past:

Check illnesses or conditions you have or had in the past: AIDs/HIV Alcoholism Allergies Antibiotic use Asthma Bleed easily Cancer Chicken Pox Diabetes Epilepsy Gallbladder Problems Glaucoma Heart Disease Hepatitis High Blood Pressure High Fevers Jaundice Kidney Problems Measles Meningitis Mental Disorders Multiple Sclerosis Mumps Pacemaker Pneumonia Polio Rheumatic Fever Scarlet Fever Stroke Thyroid Disorders Tuberculosis Typhoid Fever Ulcers Vascular Disease Venereal Disease
List any other illnesses or conditions you have or had in the past that were not listed above:
List illness(es) NOT requiring surgery
for which you have been hospitalized:
List illness(es) requiring surgery (including date)
List any other serious injury, broken hones, scars, etc.:
Is there anything you are unwilling to change in order to get well?
Have you ever taken any antibiotics? For what? How long?
List of prescription and over the counter medications you are currently taking and reason:
List allergies or sensitivity to any medicines or other substances:
What do you feel is a resonable time frame in which to reach satisfactory resolution of your primary complaint?
Name of primary doctor or physician:
Address:
Phone:
List RESULTS and DATE of last medical tests:

Physical results
Cholesterol results
Mamography results
PSA (prostate) results
Pap Smear resluts
Hepatitis, HIV, or any other test results not listed:
In the process of getting well, what % of the responsibility do you think is your own/ doctors?
Comments: (anything else you would like to tell us or talk about in your visit with us today?)
By TYPING MY NAME IN THE FIELD BELOW, I am stating that all information on this form is correct and complete to the best of my abilities. I understand I must also sign below.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Medical History (Confidential)

Medical History (Confidential)

GENERAL INFORMATION

EMERGENCY CONTACT INFORMATION

MAJOR COMPLAINT

FAMILY HISTORY

PERSONAL HISTORY