Medical History Form

Patient Name *

Date of Visit

Date of Birth *

Age

Physician Information: Please provide the names and contact information for all the doctors involved in your care.

Physician Name

Office Address

Specialty

Hospital Affiliation

Phone

Fax

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Current Medications

Name

Dosage

Frequency

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Past Medical History (check all that apply)

History of Surgery or Other Procedures

No Prior Surgeries or Procedures

Type of Surgery/Procedure

Date

Hospital/Clinic
where Performed

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Do you have an Internal Electronic Device (i.e. defibrillator/pacemaker)?
Yes No

Health Maintenance (pap, mammogram, colonoscopy, etc.)

Type

Date

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Allergies (include medications/food/environmental)

No known allergies

Allergy

Reaction

Add another?

Social History

Whom do you live with?

Do you have children?
Yes No

Do you drink alcohol?
Yes No

If you used to drink, when did you stop?

Do you/did you use tobacco products (cigars/cigarettes/tobacco)?
Yes No

Do you/did you use E-cigarettes?
Yes No

Do you use recreational drugs?
Yes No

Do you have special religious, spiritual, or cultural needs that we should be aware of?
Yes No

Do you have Advanced Directives (living will, power of attorney for health care)?
Yes No

Family History (please check all that apply)

Mother

Father

Sibling

Other

Adopted

No significant family

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