Medical History Form

Name(Required)

First Last

Date of Birth(Required)

Pronouns(Required)

Email(Required)

Other medical providers involved in my care

What areas or issues would you like to discuss today?(Required)

(Please limit to two items)

Current Medications

(lnclude birth control pills and non-prescriptive items such as vitamins, aspirin, herbs, etc.)
*Please bring your medication bottles to your office visit

Select the plus sign to add additional medications.

Medication

Dose

Time/Day

Drug Allergies

Select the plus sign to add additional drug allergies.

Medication

Type of Reaction

Personal Medical History

Have you been diagnosed with any of the following conditions?

Heart/Vascular Disease(Required)

Mental Health/Neurologic(Required)

Depression

Alcoholism

Anxiety

Substance Abuse

Migraine

Neuropathy

ADHD

Stroke

None of the above

Kidney/Bladder(Required)

Benign Prostate Hypertrophy

Erectile Dysfunction

Chronic Kidney Disease

Hypogonadism

Urinary lncontinence

Kidney Stones

PSA – Elevated

Other

None of the above

Metabolic/Nutrition(Required)

Diabetes

Anemia

Thyroid Disorder

lmpaired Fasting Glucose

Eating Disorder

Other

None of the above

Cancer(Required)

Breast Cancer

Lung Cancer

Colon Cancer

Skin Cancer

Prostate Cancer

Other

None of the above

Musculoskeletal(Required)

Rheumatoid Arthritis

Gout

Osteoarthritis

Fibromyalgia

Osteopenia

Osteoporosis

Other

None of the above

What type of Cancer?(Required)

Respiratory(Required)

Asthma

Allergies

Chronic Obstructive Pulmonary Disease

Sleep Apnea

Other

None of the above

Gastrointestinal(Required)

Peptic Ulcers

Hepatitis

GERD

IBS

Other

None of the above

Gynecological(Required)

Pap Abnormal

Ovarian Cyst

Other

None of the above

Hepatitis Type(Required)

Infectious Disease

Surgical History

What surgeries have you received?

(Please list year that specified surgery was performed)

Select the plus sign to add additional surgeries.

Surgery

Year

Other hospitalizations and serious illnesses or injuries (omit pregnancies)

Select the plus sign to add additional hospitalizations.

Hospitalization, Illness or Injury

Date

Social History

Occupation(Required)

Marital Status(Required)

Do you have children?(Required)

Yes

What are their dates of birth?(Required)

Who lives at home with you?(Required)

Do you drink alcohol?(Required)

Yes

How many servings of alcohol per day?(Required)

Do you use caffeine?(Required)

Yes

How many servings of caffeine per day?(Required)

Do you smoke tobacco?(Required)

Never

Current smoker

Former smoker

What year did you quit smoking tobacco?(Required)

How much tobacco do you smoke?(Required)

Do you use smokeless tobacco?(Required)

Never

Current user

Former user

What year did you quit using smokeless tobacco?(Required)

How much smokeless tobacco do you use?(Required)

Do you use cigars or pipes?(Required)

Never

Current smoker

Former smoker

What year did you quit using cigars or pipes?(Required)

How much do you use cigars or pipes?(Required)

Do you have passive smoke exposure?(Required)

Yes

Do you use drugs?(Required)

Never

Curent user

Former user

What drugs?(Required)

When did you quit?(Required)

Do you exercise?(Required)

Yes

What type of exercise?(Required)

Have you ever had a blood transfusion?(Required)

Yes

When did you have a blood transfusion?(Required)

Family History

Indicate which relative has had the following diseases.

Heart Disease

Mother

Father

Siblings

Other

Depression

Mother

Father

Siblings

Other

Hypertension

Mother

Father

Siblings

Other

Specify which family member has/had Heart Disease(Required)

What was the age of Heart Disease onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Depression(Required)

What was the age of Depression onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Hypertension(Required)

What was the age of Hypertension onset? If deceased, also list age at time of death(Required)

Alcoholism

Mother

Father

Siblings

Other

ADHD

Mother

Father

Siblings

Other

Asthma

Mother

Father

Siblings

Other

Specify which family member has/had Alcoholism(Required)

What was the age of Alcoholism onset? If deceased, also list age at time of death(Required)

Specify which family member has/had ADHD(Required)

What was the age of ADHD onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Asthma(Required)

What was the age of Asthma onset? If deceased, also list age at time of death(Required)

Autism

Mother

Father

Siblings

Other

Cancer

Mother

Father

Siblings

Other

Celiac Disease

Mother

Father

Siblings

Other

Specify which family member has/had Autism(Required)

What was the age of Autism onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Cancer(Required)

What was the age of Cancer onset? If deceased, also list age at time of death(Required)

Specify type of Cancer(Required)

Specify which family member has/had Celiac Disease(Required)

What was the age of Celiac Disease onset? If deceased, also list age at time of death(Required)

COPD

Mother

Father

Siblings

Other

Bleeding Disorders

Mother

Father

Siblings

Other

Anemia

Mother

Father

Siblings

Other

Specify which family member has/had COPD(Required)

What was the age of COPD onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Bleeding Disorders(Required)

What was the age of Bleeding Disorders onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Anemia(Required)

What was the age of Anemia onset? If deceased, also list age at time of death(Required)

Anxiety

Mother

Father

Siblings

Other

CVA/Stroke

Mother

Father

Siblings

Other

Dementia

Mother

Father

Siblings

Other

Specify which family member has/had Anxiety(Required)

What was the age of Anxiety onset? If deceased, also list age at time of death(Required)

Specify which family member has/had CVA/Stroke(Required)

What was the age of CVA/Stroke onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Dementia(Required)

What was the age of Dementia onset? If deceased, also list age at time of death(Required)

Thyroid Disorder

Mother

Father

Siblings

Other

Headaches

Mother

Father

Siblings

Other

Growth/Development Disorder

Mother

Father

Siblings

Other

Specify which family member has/had Thyroid Disorder(Required)

What was the age of Thyroid Disorder onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Headaches(Required)

What was the age of Headaches onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Growth/Development Disorder(Required)

What was the age of Growth/Development Disorder onset? If deceased, also list age at time of death(Required)

Liver Disease

Mother

Father

Siblings

Other

Osteoporosis

Mother

Father

Siblings

Other

Peptic Ulcer Disease

Mother

Father

Siblings

Other

Specify which family member has/had Liver Disease(Required)

What was the age of Liver Disease onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Osteoporosis(Required)

What was the age of Osteoporosis onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Peptic Ulcer Disease(Required)

What was the age of Peptic Ulcer Disease onset? If deceased, also list age at time of death(Required)

Respiratory Disease

Mother

Father

Siblings

Other

Seizure Disorder

Mother

Father

Siblings

Other

Substance Abuse

Mother

Father

Siblings

Other

Specify which family member has/had Respiratory Disease(Required)

What was the age of Respiratory Disease onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Seizure Disorder(Required)

What was the age of Seizure Disorder onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Substance Abuse(Required)

What was the age of Substance Abuse onset? If deceased, also list age at time of death(Required)

Arthritis

Mother

Father

Siblings

Other

Diabetes

Mother

Father

Siblings

Other

Specify which family member has/had Arthritis(Required)

What was the age of Arthritis onset? If deceased, also list age at time of death(Required)

Specify which family member has/had Diabetes(Required)

What was the age of Diabetes onset? If deceased, also list age at time of death(Required)

Review of Systems

Check any of the following symptoms you have experienced WITHIN THE PAST YEAR.

General(Required)

Change in Heat & Cold Tolerance

Persistent Fever

Appetite Change

Night Sweats

Swollen Glands

Fatigue

Weight Change

None of the above

Ears/Nose/Throat(Required)

Earache

Hearing Loss

Ringing In Ears

Hoarseness

Neck Swelling/Lumps

Nose Bleeds

Sinus Trouble

Other

None of the above

Urinary(Required)

Change in Urinary Stream

Blood in Urine

Frequency

Leaking Urine

Pain or Burning on Urination

Up at night to urinate

Sexual Difficulty

Other

None of the above

How much has your weight increased or decreased?(Required)

How often are you up at night to urinate?(Required)

Gastrointestinal(Required)

Mood/Mental Health(Required)

Depressed or Sad

Irritable or Angry

Anxious

Sleep Problems

Fatigue

Suicidal Thoughts

Concentration/Memory Problems

Marital, Family or Work Problems

None of the above

Skin(Required)

Change in Skin or Mole

Rash or Hives

Nail Change

Unusual Hair Loss

Other

None of the above

Bones and Joints(Required)

Back or Neck Pain

Cramps in Muscles

Painful or Stiff Joints

Swelling in Legs

Redness of Joints

Other

None of the above

Eyes(Required)

Change In Vision

Contact Lenses

Other

None of the above

Breasts(Required)

Rash of Breast

Lump

Pain

Other

Not applicable

None of the above

Heart(Required)

Chest Discomfort/Pain

Irregular Heart Beat

Racing or Fluttering Heart

Swollen Feet or Ankles

Varicose Veins

Other

None of the above

Lungs(Required)

Shortness Of Breath

Persistent Cough

Wheezing

Cough Up Blood

Other

None of the above

Neurologic(Required)

Coordination Problems

Difficulties in Speaking

Dizziness

Fainting Spells

Frequent Headaches

Muscle Weakness

Numbness or Tingling

Other

None of the above

Female(Required)

Heavy Menstrual Bleeding

Irregular Menstrual Periods

Vaginal Discharge

PMS

Other

Not applicable

None of the above

Allergy(Required)

Sneezing

Environmental Allergy

Food Allergy

Other

None of the above

Signature(Required)

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Date(Required)

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