Medical Histo

Provider you are seeing today: Patient's Name:

Please state your problem in your own words as to why you are here today: Did a physician request

Today's Date:
Date of Birth:

that you see one of our providers today?

fI

yes

D t'lo

lf yes, name of physician:

check all that a Acute Mvocardial lnfarction (Heart Attack) Anemia (Low Blood Count) Arthritis Asthma Autoimmune Disorder (Luous/Scleroderma/RA) Blood Transfusion Complications LJ Cancer - list type(s):

No Past Medical Kidnev Disease Lower Back Pain MitralValve Disorder Murmurs Obesity Obstructive Sleeo Aonea Osteoporosis Perioheral Vascular Disease (Poor Circulation) Pneumonia Pulmonarv Disease (Luno Disease) Chest Pain (Anqina) Chronic Liver Disease Recent Methicillin-resistant Staph aureus (MRSA) Rheumatic Fever COPD (Chronic Obstructive Pulmonary Disease) Seizure Disorder Diabetes Mellitus Sinusitis Emotional Disturbance Gastric/Duodenal Ulcer Stroke Svndrome Thromboembolic Disease (Blood Clot Disorder) Heart Disease Thrombophlebitis Heartburn Thvroid Disorder Heoatic (Liver) Disorder Transient lschemic Attack (Mini Stroke) Hepatitis Tuberculosis HIV lnfection Hvoercholesterolemia flOther (specify): Hvpertension lrritable Bowel Svndrome

Anemia (Low Blood Count

Health Status of Father - Deceased Health Status of Mother - Deceased

*Please indicate
the

family member affected: mother, father, brother, sister, maternal or paternal grandmother/grandfather,

etc.

(t Jefferson
Social Histolt

Medical Histo

Questionnaire

MaritalStatus: Ll
Alcohol Use

Married

Single IWidowed
Weekly: Explain: Explain:

Separated

Divorced

f,

Life Partner

(check all that apply):

E E E E

Orug Use (Recreational) Using lntravenous Drugs

Quit: Attempts to Quit:

Previous History of Smoking Packs Per Date No History of Smoking Wisning to Stop Smoking Smoking/Nicotine Substances

Day:

Years of Smoking:

Methods Used to Quit:

! ! ! I

E Cigarettes E
Explain: Times per week:

Cigars

[_J Chewing

Tobacco Ll

PiPe

Packs/Times Per Day:

L_l Current Diet

Years:

Exercise Habits

aeing Sedentary (Do not exercise) l--l Sexuallv Active

L_l Occupation

List All:

[_] Travel Do you have an advanced directive?

lf recently out of the country, where?

yes

tr

tto

nclude vi

herbal su

and over the counter medications

No Current Medications

Have you participated in any clinicaltrials or used experimental drugs?

Yes

E tto Explain:

Are you pregnant?

Yes

tto

Last Menstrual Period Date:

ls there anything else about your medical history that we should know?

Patient Signature:
I certify that I have reviewed the above information with the patient.

Date:

Physician Signature:

Date: