Health History Form

Patient Information

Patient Name:	( First Last )
E-Mail Address :
Age:
Birthdate:
Date of last Physical Examination:
Primary Care Physician :
Referring Physician , if different from above :
What is your reason for visit ?

Symptoms

General Symptoms

Chills	Depression	Dizziness	Fainting
Fever	Forgetfulness	Headache	Loss of Sleep
Loss of Weight	Nervousness	Numbness	Sweats

Muscle / Joint / Bone Symptoms

Pain weakness or numbness in :

Arms	Hips	Back	Legs
Feet	Neck	Hands	Shoulders

Genito-Urinary Symptoms

Blood in Urine	Frequent Urination	Lack of Bladder Control	Painful Urination

Gastrointestinal

Appetite Poor	Bloating	Bowel Changes	Constipation
Diarrhea	Excessive Hunger	Excessive Thirst	Gas
Hemorrhoids	Indigestion	Nausea	Rectal Bleeding
Stomach Pain	Vomiting	Vomiting Blood

Cardiovascular

Chest Pain	High Blood Pressure	Irregular Heart Beat	Low Blood Pressure
Poor Circulation	Rapid Heart Beat	Swelling of Ankles	Varicose Veins

Eye, Ear, Nose, Throat

Bleeding Gums	Blurred Vision	Crossed Eyes	Difficulty Swallowing
Double Vision	Earache	Ear Discharge	Hay Fever
Hoarseness	Loss of Hearing	Nosebleeds	Persistent Cough
Ringing In Ears	Sinus Problems	Vision - Flashes	Vision-Halos

Skin

Bruise Easily	Hives	Itching	Change in Moles
Rash	Scars	Sore That Wont Heal

MEN Only

Breast Lump	Erection Difficulties	Lump in Testicles	Penis Discharge
Sore on Penis	Other

WOMEN Only

Abnormal Pap Smear	Bleeding Between Periods	Breast Lumps	Extreme Menstrual Pain
Hot Flashes	Nipple Discharge	Painful Intercourse	Vaginal Discharge
Other
Date of Last Menstrual Period:
Date of Last Pap Smear:
Have You Had A Mammogram ?
Are You Pregnant?
Number Of Children:

Conditions

AIDS / HIV	Chemical Dependency	High Cholesterol	Psychiatric Care
Alcoholism	Chicken Pox	Kidney Disease	Rheumatic Fever
Anemia	Diabetes	Liver Disease	Scarlet Fever
Anorexia	Emphysema	Measles	Stroke
Appendicitis	Epilepsy	Migraine Headaches	Suicide Attempt
Arthritis	Glaucoma	Miscarriage	Syphilis
Asthma	Goiter	Mononucleosis	Thyroid Problems
Bleeding Disorders	Gonorrhea	Multiple Sclerosis	Tonsilitis
Breast Lump	Gout	Mumps	Tuberculosis
Bronchitis	Heart Disease	Pacemaker	Typhoid Fever
Bulimia	Hepatitis	Pneumonia	Ulcers
Cancer	Hernia	Polio	Vaginal Infections
Cataracts	Herpes	Prostate Problem	Venereal Disease

Medications:

List medications you are
currently taking:

Pharmacy:

Pharmacy Phone:

Allergies :

Are you allergic to any
medications?

If yes, please list all
medications to which you
are allergic :

Please list any
other known allergies:

Family History :

Relation	Age	State of Health	Age at Death	Cause of Death
Father
Mother
Brother 1
Brother 2
Brother 3
Brother 4
Sister 1
Sister 2
Sister 3
Sister 4

Check if your blood relatives had any of the following :

Disease :

Relationship to You :

Arthritis, Gout

Asthma, Hay Fever

Cancer

Chemical Dependency

Diabetes

Heart Disease, Strokes

High Blood Pressure

Kidney Disease

Tuberculosis

Other

Hospitalizations :

Please list all hospitalizations including YEAR, HOSPITAL, and REASON for Hospitalization, and OUTCOME :

Have you ever had a Blood Transfusion ?

If YES, please give
approximate dates:

Serious Illness/Injuries :

Please list all Serious Injuries including TYPE OF INJURY, YEAR, and OUTCOME :

Pregnancies :

Please list all Pregnancies including YEAR OF BIRTH, SEX, and COMPLICATIONS if any :

Health Habits :

Substance Used :

How Much / Frequency :

Caffeine

Tobacco

Drugs

Other

Occupational :

Check if your work exposes you to the following :

Stress

Hazardous Substances

Heavy Lifting

Other

Your Occupation :

Residence :

List states or foreign
countries of prior
residence with dates:

List domestic and/or
international travel
with dates:

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form