Download Past Medical History

Patient's Name:
Height:___ Weight:___
Reason for Visit:
Current MD:
Past Medical History
 No Medical Diagnosis
Have you ever had or been treated for 
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Lung Disorder
Anemia
Anesthesia problem
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Back Problems
Bladder Infections
Bleeding Disorder
Blood Clots / CVT
Blood Transfusions
Bronchitis
Cancer
Cataracts
Chicken Pox
Congenital/
Deformities
Congestive Heart
Failure
COPD / Emphysema
Crohns / Ulcerative
Colitis
Dementia
Depression
Diabetes
Diphtheria
Diverticulosis
Eczema
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Epilepsy / Seizures
Fibromyalgia
GERD/ Heartburn
Glaucoma
Gout
Heart Attack
Heart Disease / CAD
Heart Murmur
Heart Palpitations
Heart Valve Disease
Hemorrhoids
Hepatitis
High Blood Pressure
High Cholesterol
HIV/ AIDS
Hyperthyroid /
Hypothyroid
Infectious
Mononucleosis
Insomnia / Sleep
Disorder
Irregular Heart Beat
Irritable Bowel
Syndrome
Kidney Disease
Kidney Stones
Liver Disease/
Cirrhosis
Low Blood Pressure
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Lupus
Malaria
Measles
Migraine Headache
Mitral Valve Prolapse
Mumps
Neurological Disease
Neuropathy
Osteoporosis
Pacemaker
Pancreatitis
Parkinson's
Peptic (Stomach)
Ulcers
Peripheral Vascular
Disease
Pneumonia
Polio
Prostate
Enlargement
Pulmonary Embolism
Rheumatic Fever
Rheumatoid Arthritis
Scarlet Fever
Seasonal Allergies
Sexually Transmitted
Diseases
Shingles
Sleep Apnea
 Smallpox
 Stroke / TIA
 Tuberculosis
 Urinary Incontinence
 Vertigo
 Whooping Cough
Other:_______________
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Family Medical History
Family History 
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Anemia
Arthritis
Asthma
Blood Clots/DVT
Cancer
COPD/Lung Disease
Depression
Diabetes
Heart Disease/CAD
Hepatitis
High Blood Pressure
High Cholesterol
HIV/AIDS
Irregular Heartbeat
Liver Disease
Osteoporosis
Prostate
Stomach Ulcer/Reflux
Stroke/Seizures
Vascular Disease
Thyroid Disease
Vascular Disease
Relation –
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Other:_______________
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Smoking Status:
 Current every day
smoker (1)
 Current some day
smoker (2)
 Former smoker (3)
If yes, Packs/day: ___
 Never smoker (4)
 Smoker, current
status unknown (5)
 Unknown if ever
smoked
Number of Years: ___
 Heavy tobacco
smoker
 Light tobacco smoker
Quit Date: __/__/____
Alcohol Use Status:
 Does not drink
 currently drinks
If yes, Alcohol Type: _____________
 Did not ask
 Former drinker
Drinks/Week: _____________
 Quit
Quit Date: __/__/____
Illicit/Illegal drugs
Status:
 Does not take drugs
 Currently takes drugs
 Did not ask
 Former drug user.
 Quit
If yes, Drug Type: _____________ Quit Date:__/__/____
Injury Information
Type of Injury:
 Work
 Auto
 Sports
 Other
If yes, Injury Date: __/__/____ Injury Details: _________________________________________
Hospitalization/Surgeries
Surgery/Procedure
Hospital
Date
Comments
Patient Allergies
 No known drug Allergies.
Allergy
Severity
(Mild, Moderate, Severe)
Date
Comments
Review of Systems (Last 30 days’ time)
Constitutional
 Unexplained Weight
Change
 Change in Appetite
 Fever
Eyes
 Changes in Vision
 Glasses/Contact Lenses
Ears
 Hearing Difficulty
 Hearing Aids
Nose/ Throat
 Nosebleed/ Bleeding
Gums
 Dentures
 Difficulty Swallowing
Respiratory
 Chronic Cough
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Gastrointestinal
 Stomach Pain
 Nausea/ Vomiting
 Diarrhea
 Constipation
Neurological
 Headaches/ Dizziness
 Numbness/ Tingling
of Hands
Endocrine
 Excessive Thirst
 Ringing in Ears
 Shortness of Breath
Cardiovascular
 Fainting
 Chest Pain at Rest
 Chest Pain with
Exercise
Musculoskeletal
 Joint Swelling
 Fatigue
Foot/ Ankle Swelling
Abnormal EKG
Abnormal Chest Xray
Palpitations
 Asthma
 Blood in Stool
 Blood in Urine
 Muscle Weakness
 Numbness/ Tingling
of Feet
 Loss of
consciousness
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Memory loss
Back pain
Speech difficulties
Neck pain
Hematological
 Bruise Easily
 Skin Rashes or Sores
Psychiatric
 Depression
 Confusion
 Anxiety
 Nervousness
Current Medications
Drug name
Dosage
Quantity
Prescription
Date
Prescribed By