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Healthy Lifestyle
9273
Your Doctor and You
Medical History Form
Medical History Form
htmMedicalHistory
Fill out this useful form before you head to your doctor. Your doctor's visit will be much more productive if you can provide accurate information.
327177
InteliHealth
2011-09-06
t
InteliHealth Medical Content
2014-09-06
Reviewed by the Faculty of Harvard Medical School

MEDICAL HISTORY FORM

Complete this form before going to the doctor, especially if this is your first visit.


Personal Information

Name:
Date:


Emergency Contact

Name:
Relationship:
Phone number:
 


Insurance Information

Insurance carrier:
Policy number:


Health Information

List any other physicians who are treating you.

Name

Specialty 

Phone
 
 
 
 
 
 
 
 
 

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.

  1)
5)
  2)
6)
  3)
7)
  4)
8)

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?


Screening Tests

Have you ever had tuberculosis (TB) or a positive skin test for tuberculosis?


  Yes (provide date):
No

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)?

  Yes (provide date):
No


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:

  ___Normal
____ Abnormal

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


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