Patient Health History Form

Health History Form


All information is strictly confidential.

Today's Date

Name

Age

Reason for Visit

For Injuries
Date of Injury

On the job?

Occupation

Height

Weight

What is the most you have ever weighed

Past Medical History
Please check if you have, or ever had any of the following conditions:

Cardiovascular

Respiratory

Gastro-intestinal

Blood

Neurologic

Blood

Mental Health

Skin/Skeletal

Immune/Infection

Endocrine

Others

Impairment

Cancer

Are you being treated for any other illness at this time?

If yes, please explain:

Date of Last Physical

Results

Have you ever had Surgery?

If yes, please list

Have you, or a family member ever had a problem with anesthesia?

If yes, please explain

Have you been diagnosed with a sleep disorder/sleep apnea?

Do you use a C-Pap Machine for your sleep disorder?

Do you have any Drug Allergies?

If yes, please note name of drug and reaction:

Family History
Only list blood-related relatives.

Diabetes

Stroke

Blood Clots

Heart Disease

High Blood Pressure

Cancer/Type

Other

List all medications you are taking with name and dosage

Weight Control

Accutane (past year)

Antibiotics

Aspirin/NSAID's

Blood Thinners

Birth Control

Estrogen/Hormones

Chemotherapy

Antidepressants

Steroids

Vitamins/Supplements

Herbal/Homeopathics

Are you taking or have you ever taken recreational drugs?

What type

Please give more details

Do you smoke?

Quit?

How much per day?

Do you drink?

Additional Health History
(Female Gender or FtM, please complete)

Pregnancies

Live Births

Miscarriages

Abortions

Date of Last Menstrual Period

Are you pregnant?

Date of Last Mammogram

Results

Breast Cancer

History of Breast Biopsy

Current Bra Size (Female Gender Only)

Review of Systems
Select the following symptoms you have had recently.

General

Eyes, Ears, Nose & Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Neurologic

Psychiatric

Heme/Immunologic

Endocrine/Hormonal

Skin Disease

Breasts

To the best of my knowledge, the above information is complete and correct. I understand it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

Signature of Patient, Parent, Guardian, or Personal Representatives

Date

Time

Name of Patient, Parent, Guardian or Personal Representative

Date

Time

admin none 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 6:00 PM