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PATIENT MEDICAL HISTORY

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Name
Age
DOB
  Right Handed Left Handed
Reason for Visit
Social History
Married Single Partner Same/Opposite Divorced Widowed
Cigerettes/Cigars Yes No      Packs per day
Alcohol Yes No      Drinks per day Per week
Recreational Drugs Yes No      Name
Caffeinated beverages Yes No      Per day
What type of work do you do?
Do you do any heavy lifting at work? Yes No 
Are you currently disabled? Yes No 
List any allergies to medications, IV dye, or foods
Family History (list blood relative)
Epilepsy Neuropathy
Migraine Alzheimer’s
Mental illness High Blood Pressure
Diabetes Alcoholism
Parkinson’s Genetic Disease
Neuropathy Cancer
High Cholesterol Tremor
Heart Disease Multiple Sclerosis
Stroke      
Previous Hospitalizations
Year Illness/operation Where
Year Illness/operation Where
List any prior significant injuries
How Long?
System Review/Past Medical History (Check problems you have now or in the past)
General
Neurologic
Cardiovascular
Weight Loss Convulsion/seizure Chest pain/tightness
Weight Gain Stroke Heart murmur
Cancer Headaches-severe Irregular pulse
Excessive Thirst Migraine High Blood Pressure
Fever Tremor/shaking High Cholesterol
fatigue
Genitourinary
Palpitations
Eyes
No bladder control
Hematology
Failing vision Venereal Disease Anemia
Eye pain
Psychiatric
Bruise easily
double or blurred Nervousness contact with bodily fluids
Glaucoma Depression Exposure to HIV
Cataracts Memory Loss
Gastrointestinal
Musculoskeletal
Mental Illness
Loss Of appetite (recent)
Osteoporosis
Respiratory
Difficult to swallow
Muscle Weakness Asthma/chronic cough Indigestion
numbness/ Tingling
 Pneumonia/Pleurisy nausea/vomiting
Arthritis Bronchitis/Emphysema Peptic ulcer
Back Pain Shortness of Breath Abdominal Pain
Joint injury/Gout Wheezing Jaundice/hepatitis
Head, Ears, Nose, Throat
Skin
Diarrhea
Sinus Pain Rashes Constipation
Hoarseness Hives    
Decreased hearing
Endocrine
   
Ringing in the ears Diabetes    
Sleep
Thyroid Disease    
Sleeping difficulty (Female) Day of last period    
Snoring        
Patient Name
Please List all current medications including non-prescriptions.
Name Dosage Name Dosage
List any allergies to medications, IV dye, or foods
Please check Chronic/current illness
Asthma Seizure disorder
Hypertension Migraine
Diabetes Headaches
Coronary Disease Cluster Headache
Cardiac arrythmias Stroke
Peripheral vascular Disease Parkinson’s
Hyperlipidemia Guillian Barre
Thyroid Disease Neuropathy
Depression Multiple Sclerosis
Schizophrenia Myastenia Gravis
Bipolar Disorder Dystonia
Personality Disorder Dementia
Substance Use Other List Below
ADHD  
Alzheimer’s  
Epilepsy  
Migraine