Patient History Form - Free Download | Page 2
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Patient History Form Page 2
Medical History Form 3
Family Medical History
Please indicate (X) all family members* medical history (*Mother / Father, Brother / Sister, Grandmother / Grandfather) :
Relationship Relationship Relationship
PAST Personal Medical History
Immunizations and date completed:
Hepatitis A
Tetanus
Pneumonia Rubella
Polio
Hepatitis B Flu Shot
Measles Varicella (chicken pox)
Zostervax
Travel Vaccinations:
** Please indicate (X) and provide details for any PASTMedical History (i.e. diagnosis, dates).
Surgery or Procedure
Other Hospitalizations
Transfusion
Heart problems
Blood Pressure problems
Diabetes: Type I Type II
Date of last Cholesterol test & results
Stroke
Cancer
EENT problems (eye, ear, nose and throat):
Lung problems
Gastrointestinal problems Last colonoscopy date & results
Kidney or Bladder problems
Neurologic problems
Skin problems
Bone / Muscle / Joint problems
Thyroid or other Endocrine problems
Blood Disorders
Depression / Suicide attempt or other psychiatric problems
FEMALE: Gynecological problems
Date of last Mammogram & results Ever abnormal
Abnormal breast symptoms (describe on next page)
Breast Implants
Date of last Pap Smear & results Ever abnormal
MALE: Prostate problems / sexual dysfunction Date of last PSA & results
Other medical problems not previously mentioned
page 2.
Patient Name:
Heart Disease
High Blood Pressure
Diabetes
High Cholesterol
Stroke
Cancer (Incl. type)
Heart Disease
High Blood Pressure
Diabetes
High Cholesterol
Stroke
Cancer (Incl. type)
Blood Disorder
Stomach Disease
Obesity
Drug/Alcohol Abuse
Mental Illness
Other
Elevated Cholesterol/Lipids
Y N
Y N
Y N
NY
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