MEDICAL HISTORY

MEDICAL HISTORY (Male and Female)
Full Name *

First Name Last Name
PRIMARY CARE PHYSICIAN (if none, write NONE) *
City and State of PCP
Preferred Pharmacy
Birth Date *

Month Day Year
DATE: *

Month Day Year
Dr. Smith would like a brief synopsis of the following.
History of present illness: (when pain started/noticed, physician visits, diagnosis, procedures, etc.) *
Medical History: list any illness, disease/sicnkess you have had in the past (chronic/acute) *
Surgical History: List any surgeries/invasive procedures you have had. *
Gynecological History (Women Only)
How many pregnancies have you had?
Full Term
Premature
Miscarriage/Abortion
Living Children
Where there complictaions during pregnancy, labor, delivery or post partum?

Yes No
If yes:

Episiotomy Vaginal lacertation C-section Forceps Vacuum Medication for bleeding Post-partum hemorrhaging
Other?
Do you have any pain with your periods?

Yes No
Family History

List family medical History
Mother:
Father:
Siblings: List brother (s) or sister (s)
Grandparents: List Maternal or paternal
Social and Health History:
Occupation/former Occupation:
Marital Status: *

Married Single Widowed Divorced Life Partner
Health Habits
Height and Weight *
Average Blood Pressure Reading:
Alcohol Use: *
Have you ever received treatment for substance abuse?

Yes No
What is your use of recreational drugs? *
If you use, what ?
Tobacco History:
Have you ever used tobacco? *
if Yes, How much? (Packs/day?)
Start Date:

- Month - Day Year
Quit Date:

- Month - Day Year
Medications:
Medication allergies and reactions (hives, rash, etc.) *
Prescription/non-prescription Medications/Supplements (include how many you take, and the strength *
Review of Systems:
Constitutional (how are you feeling in general?)
Head (headaches, pain, dizziness?)
Neck (pain, stiffness?)
Eyes (pain, difficulty seeing, blurred vision...?
Ears (difficulty hearing, ringing, pain, infections...?)
Nose (sinus problems, pain...?)
Mouth (pain....?)
Throat (pain, hoarseness, scratchy, laryngitis...?)
Cardiovascular (heart)
Respiratory (lungs)
History of Rectal Bleeding?

No Yes
Do you have pain or discomfort that is associated with the following?
Does your pain improve after completing a bowel movement?

Yes No
Genitourinary (bladder, prostate, kidney, genitals)
Musculoskeletal (bone/joint pain, arthritis...)
Skin (Eczema, oily, moles) and Breast (pain, lumps....)
Neurological (numbness, tingling)
Psychiatric (anxiety, depression, addictions)
Lymphatic (lymphnodes, blood disorders):
Endocrine (thyroid, diabetes)
If you have any other information you would like to share with the Doctor you can upload it here.
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MEDICAL HISTORY (Male and Female)

Gynecological History (Women Only)

Family History

Social and Health History: