| Healthy Lifestyle Your Doctor and You Medical History Form dmtContent 
MEDICAL HISTORY FORM Complete this form before going to the doctor, especially if this is your first visit.
Personal Information
Emergency Contact Name: | Relationship: | Phone number: | |
Insurance Information Insurance carrier: | Policy number: |
Health Information List any other physicians who are treating you. What are the major concerns for your visit today? 1)
2)
3)
4)
Your Medical History List all of the conditions for which you have received medical treatment, either now or in the past. List any surgery (major or minor) you have undergone. Procedure: | Date: | Procedure: | Date: | Procedure: | Date: | List all of the times you have been hospitalized. Date: | Reason: | Date: | Reason: | Date: | Reason: | List any medications that you currently take (include prescription drugs, over-the-counter treatments, vitamins, etc.). And list the doses, if known. Drug: | Dose: | Drug: | Dose: | Drug: | Dose: | Drug: | Dose: | Drug: | Dose: | Drug: | Dose: |
List any allergies or bad reactions you have had to medications. Drug: | Reaction: | Drug: | Reaction: | Drug: | Reaction: |
Vaccinations Have you ever had any of the following vaccinations? - Tetanus vaccine
- Influenza (flu) vaccine
- Pneumococcal (pneumonia) vaccine
- Hepatitis A vaccine
- Hepatitis B vaccine
- Bacille Calmette-Guerin (BCG) vaccine (for tuberculosis)
- Meningococcal meningitis vaccine
Screening Tests Have you ever had tuberculosis (TB) or a positive skin test for tuberculosis?
When was your most recent cholesterol test, and what were the results (approximately)?
Have you ever undergone a screening test for colon cancer (sigmoidoscopy or colonoscopy)?
Lifestyle Habits Do you now or have you ever used tobacco?
Do you drink alcohol?
Do you get regular exercise?
Do you follow any special diet?
For Women Date of last menstrual period: Previous pregnancies: Date of last Pap smear: Date of last mammogram:
Your Family History Relative | Alive? | Age
(or age at death) | Medical problems* | Mother | | | | Father | | | | Brother/sister | | | | Brother/sister | | | | Brother/sister | | | | Brother/sister | | | | Mother's mother | | | | Mother's father | | | | Father's mother | | | | Father's father | | | | | *Include heart disease, hypertension, diabetes, stroke, kidney problems, cancer (breast, lung, prostate, liver, colon, ovarian, uterine, cervical), thyroid disease, alcoholism or drug abuse, depression or anxiety, osteoporosis and arthritis
Systems Review Circle any problems you may be experiencing and give details below: Abdominal pain | Ankle swelling | Anxiety or stress | Back pain | Bleeding in bowel movements | Breast lumps | Burning or difficulty passing
urine | Chest pains or heaviness | Constipation | Cough | Dental problems | Depression | Diarrhea | Difficulties with vision | Difficulty breathing or
shortness of breath | Difficulty swallowing | Difficulty with sexual
function | Dizzy spells | Dry or red eyes | Dry mouth | Easy bruising or bleeding | Fatigue | Fevers or chills | Fluid leaking from nipples | Frequent falls or unsteadiness | Frequent urination | Gas | Goiter | Headaches | Hearing problems | Indigestion or heartburn | Irregular menstrual periods | Joint pains or swelling | Loss of appetite | Loss of bladder control | Low sexual drive | Moles or worrisome spots on skin | Nausea or vomiting | Numbness or tingling | Palpitations | Panic attacks | Poor memory | Poor sleep | Rash | Seasonal allergies | Sinus infections or
stuffiness | Stiff neck | Swollen glands | Weakness | Weight loss or gain | Wheezing | Details: FOLLOW-UP Complete this portion of the form during or after your visit with your doctor. Blood pressure: _____/_____ | Weight: __________ | Results of your physical examination: What tests (if any) did your doctor perform or order today? Blood tests | Pap smear | Stress test | Stool cards | Urinalysis | Bone density | Echocardiogram | Sigmoidoscopy | X-rays | Colonoscopy | Biopsy | Mammogram | Electrocardiogram (ECG) | Other | When and how will you receive your results? Did your doctor refer you to any other health professionals? Name:
Telephone number:
Specialty:
Date of appointment: Your Doctor's Recommendations Changes in medication: Changes in diet or exercise: Preventive tests or treatment: When is your next doctor's visit? Date:
Time: Last updated September 06, 2011 | 
