Past Medical History Information
Today's Date:
Patient's Name:
Social Security Number:
Date of Birth:
Primary Care Physician:
Date of Last Exam:
Reason For Today's Visit:
Please list your past surgeries/hospitalizations with dates: :
Please check Yes if you have or No if you do not have each of the medical conditions listed below.
Angina (chest pain)
Yes
No
Hypertension (high blood pressure)
Yes
No
Diabetes (high blood sugar)
Yes
No
Renal Disease (kidney disease)
Yes
No
Respiratory Illness (lung problems)
Yes
No
Please list type(ie. asthma, COPD, etc.):
Bleeding Disorder
Yes
No
Seasonal Allergies
Yes
No
HIV/AIDS
Yes
No
Cancer
Yes
No
Please list type of cancer:
Sinus Problems
Yes
No
Recent Viral Illness (flu-like illness)
Yes
No
Please describe any current or past medical condition or treatment not listed above:
Is there a family history of the illness/condition we are seeing you for today? If so, please specify relationship of family member.
Please list your drug allergies:
Do you currently smoke or chew tobacco?
Yes
No
If no, have you in the past?
Yes
No
How many packs per day?
Do you drink alcohol, beer, or wine?
Yes
No
If no, have you in the past?
Yes
No
How often?
By placing a check in the box below, I hereby certify that to the best of my knowledge all the information I have furnished on this form
is complete, true and accurate.
I Agree That All Of The Submitted Information Is Correct:
Please make a selection.
Today’s Date:
