Patient Medical History
Name
Age
Are you
Left or
Right-handed
Home Phone
Cell Phone
Primary/Referring Physician
Pharmacy Name
Address
Phone
Chief Complaint (why are you here?)
Briefly describe the history of your problem
Please check if you have had any of the following
Back Pain
Bladder Changes
Blurred Vision
Confusion
Constipation
Convulsions
Rash
Chest Pain
Diarrhea
Dizziness
Double Vision
Fainting
Involuntary Movement
Headaches
Depression
Anemia
Hearing Loss
Fever
Memory Loss
Muscle Wasting
Neck Pain
Numbness
Insomnia
Loss of Smell
Pains
Palpitations
Paralysis
Ringing in the Ears
Edema
Tingling
Cough
Tremors
Uncoordination
Unsteadiness
Weight Loss/Gain
Sleep Disturbance
Loss of Appetite
Shortness of Breath
Allergies
Past Medical History (please list all medical problems)
Do you have a Pacemaker?
Yes
No
Do you have a Defibrillator?
Yes
No
Hospitalizations/Surgeries (dates and reasons)
Please check any conditions that you have now or have had in the past
Diabetes
Seizures
High Blood Pressure
Stroke
Head Injury
High Cholesterol
Heart Disease
Other
Please Explain
List all medications including vitamins, supplements and herbal medicines that you are currently taking with dosages
Family Medical History (Please list medical problem and family member affected)
Do you smoke?
Yes
No
If yes, how much?
For how long?
Do you drink alcohol
Yes
No
If yes, how much?
How often?
Do you use marijuana, cocaine and/or any unprescribed drugs
Yes
No
If yes, which one?
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Race
Occupation (please indicate if retired)
Additional comments or specific questions
I have answered the questions truthfully and to the best of my knowledge, without intent to falsify information. I understand that incorrect information I may have provided could affect recommended treatment and ultimately affect the course and outcome of my medical condition.
Patient Signature
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Date