Medical History Form

Date

Name

First Last

Past Medical History*

If Other, Please Explain

Please Check ALL Current Positive Findings

Constitutional*

Weight Loss
Fever
Chills
Poor Appetite
Fatigue
Weight Gain
Insomnia
Night Sweats
None

Eyes*

Blurry Vision
Eye Pain
Eye Redness
Decrease in Vision
Dry Eyes
Double Vision
None

ENT*

Sore Throat
Hoarseness
Ear Pain
Hearing Loss
Ear Discharge
Nose Bleed
Tinnitus
Sinus
None

Cardiovascular*

Chest Pain
Palpitations
Rapid Heart Rate
Heart Murmur
Poor Circulation
Swelling Legs/Feet
None

Respiratory*

Shortness of Breath
Chronic Cough
Coughing Up Blood
Hx of Tuberculosis
Excess Sputum
None

Gastrointestinal*

Nausea
Vomiting
Diarrhea
Constipation
Blood in Stool
Frequent Heartburn
Trouble Swallowing
None

Skin*

Rash
Hives
Hair Loss
Skin Sores
Itching
Skin Thickening
Hair Changes
Mole Changes
None

Musculoskeletal*

Joint Pain
Muscle Aches
Leg Cramps
Muscle Weakness
Bone Pain
Joint Swelling
Back Pain
None

Psychiatric*

Anxiety
Depression
Alcohol/Drug Dependence
Suicidal Thoughts
Panic Attacks
None

Endocrine*

Goiter
Heat Intolerance
Cold Intolerance
Increase Thirst
Change in Skin Color
Excess Sweating
None

Neurological*

Seizures
Tremors
Migraines
Numbness
Dizziness/Vertigo
Loss of Balance
Slurred Speech
Stroke
None

Hem/lymphatic*

Low Blood Count
Easy Bruising
Swollen Lymph Nodes
Transfusions
Bleeding
Blood Clots
None

Allergic/Immune*

Allergic Reactions
Hay Fever
Frequent Infections
Hepatitis
HIV +
+ Tuberculosis Test
None

Social History

Marital Status*

Occupation*

Smoking History*

Non-Smoker
Former Smoker
Current Smoker

How many cigarettes per day?

Alcohol Useage*

2-4 drinks per week
2 or more drinks per day
Weekend Drinking
Occasional Drinking
Binge Drinking (More than 4 drinks per occasion)
Do Not Consume Alcohol

Family History

Father

Mother

Sibilings

Children

Any Additional Information?

Please Check ALL Current Positive Findings

Social History

Family History