HEALTH HISTORY

TODAY’S DATE:

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PATIENT INFORMATION

Patient First Name

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Patient Last Name

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DOB:

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PREVIOUS OR REFERRING DOCTOR:

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Preferred Pharmacy:

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Date of last physical exam:

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PERSONAL HEALTH HISTORY

Immunizations and dates:

Tetanus

Date:

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Pneumonia

Date:

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Hepatitis

Date:

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Influenza

Date:

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MMR

Date:

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COVID-19

Date:

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Other

Date:

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LIST ANY MEDICAL PROBLEMS DIAGNOSED BY A PROVIDER

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SURGERIES

Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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OTHER HOSPITALIZATIONS

Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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MEDICATIONS

Medication

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Strength

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Frequency Taken

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Medication

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Strength

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Frequency Taken

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Medication

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Strength

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Frequency Taken

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Medication

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Strength

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Frequency Taken

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Medication

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Strength

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Frequency Taken

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ALLERGIES TO MEDICATIONS

Medication

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Reaction

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Medication

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Reaction

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Medication

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Reaction

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Medication

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Reaction

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Medication

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Reaction

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Medication

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Reaction

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HEALTH HABITS

Exercise

Sedentary

Yes

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Mild exercise

Yes

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Occasional vigorous exercise

Yes

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Regular vigorous exercise

Yes

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Diet

Are you dieting?

Yes

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If yes, are you on a physician prescribed medical diet?

Yes

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# of meals you eat in an average day?

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Alcohol / Tobacco

Do you drink alcohol?

Yes

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How many drinks per week?

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Do you use tobacco?

Yes

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Cigarettes

pks./day:

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Chew

#/day:

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Pipe

#/day:

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Cigars

#/day:

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# of years:

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Or year quit:

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Recreational Drugs

Do you currently use recreational or street drugs?

Yes

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Have you ever given yourself street drugs with a needle?

Yes

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PERSONAL SAFETY

Do you live alone?

Yes

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Do you have frequent falls?

Yes

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Do you have vision or hearing loss?

Yes

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Is stress a major problem for you?

Yes

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Do you feel depressed?

Yes

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Do you panic when stressed?

Yes

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Do you have problems with eating or your appetite?

Yes

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Do you cry frequently?

Yes

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Have you ever attempted suicide?

Yes

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Have you ever seriously thought about hurting yourself?

Yes

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Do you have trouble sleeping?

Yes

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Have you ever been to a counselor?

Yes

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WOMEN’S HEALTH (IF APPLICABLE)

Age at onset of menstruation:

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Date of last menstruation:

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Period every

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Heavy periods, irregularity, spotting, pain, or discharge?

Yes

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Number of pregnancies:

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Number of live births:

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Are you pregnant or breastfeeding?

Yes

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Have you had a D&C, hysterectomy, or Cesarean?

Yes

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Any urinary tract, bladder, or kidney infections within the last year?

Yes

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Any blood in your urine?

Yes

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Any problems with control of urination?

Yes

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Any hot flashes or sweating at night?

Yes

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Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

Yes

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Experienced any recent breast tenderness, lumps, or nipple discharge?

Yes

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Date of last pap and rectal exam?

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MEN’S HEALTH (IF APPLICABLE)

Do you usually get up to urinate during the night?

Yes

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If yes, # of times

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Do you feel pain or burning with urination?

Yes

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Do you usually get up to urinate during the night?

Yes

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Any blood in your urine?

Yes

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Do you feel burning discharge from penis?

Yes

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Has the force of your urination decreased?

Yes

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Have you had any kidney, bladder, or prostate infections within the last 12 months?

Yes

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Do you have any problems emptying your bladder?

Yes

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Any difficulty with erection or ejaculation?

Yes

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Any testicle pain or swelling?

Yes

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Date of last prostate and rectal exam?

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HEALTH HISTORY

PATIENT INFORMATION

PATIENT INFORMATION

PERSONAL HEALTH HISTORY

PERSONAL HEALTH HISTORY

Immunizations and dates:

SURGERIES

SURGERIES

OTHER HOSPITALIZATIONS

OTHER HOSPITALIZATIONS

MEDICATIONS

MEDICATIONS

ALLERGIES TO MEDICATIONS

ALLERGIES TO MEDICATIONS

HEALTH HABITS

HEALTH HABITS

Exercise

Diet

Alcohol / Tobacco

Recreational Drugs

PERSONAL SAFETY

PERSONAL SAFETY

FAMILY HEALTH HISTORY

FAMILY HEALTH HISTORY

Father

Mother

Sibling(s)

Children(s)

Grandparent(s)

MENTAL HEALTH

MENTAL HEALTH

WOMEN’S HEALTH (IF APPLICABLE)

WOMEN’S HEALTH (IF APPLICABLE)

MEN’S HEALTH (IF APPLICABLE)

MEN’S HEALTH (IF APPLICABLE)

OTHER PROBLEMS / SYMPTOMS

OTHER PROBLEMS / SYMPTOMS

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