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Health History Form / Medication History Form
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Health History Form / Medication History Form
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Health History Form / Medication History Form
I. Chief Complaint and Present Illness
First Name
*
Last Name
*
Email Address
*
Phone Number
*
Reason for Visit Today
Duration of Symptoms
Symptom Details
Other Providers Seen
II. Past Medical History (PMH)
Cardiovascular
High Blood Pressure
High Cholesterol
Heart Attack
Stroke
Atrial Fibrillation
Congestive Heart Failure
Pulmonary
Asthma
COPD/Emphysema
Pneumonia
Tuberculosis
Endocrine
Type 1 Diabetes
Type 2 Diabetes
Thyroid Disorder
Gastrointestinal
GERD/Reflux
Crohn's Disease
Ulcerative Colitis
Liver Disease (Hepatitis)
Mention other Past Medical History
Date of Last Physical Exam
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Health History Form / Medication History Form
III. Past Surgical History (PSH)
Please list all surgeries you have had:
1st Surgery's Name
1st Surgery's Year
1st Surgery's Surgeon/Hospital
2nd Surgery's Name
2nd Surgery's Year
2nd Surgery's Surgeon/Hospital
3rd Surgery's Name
3rd Surgery's Year
3rd Surgery's Surgeon/Hospital
IV. Medication and Allergy History
Please list all medications, vitamins, and supplements you are currently taking (including over-the-counter):
Medication Name
Dosage (e.g., 10 mg)
Frequency (e.g., daily)
Prescribing Doctor
Allergies
Allergen (Medication, Food, Environmental)
Type of Reaction (e.g., Rash, Hives, Anaphylaxis)
Social History
Smoking Status
Never
Current (Packs per day/Years)
Former (Date quit)
Alcohol Use
Never
Current (Drinks per week)
Former (Date quit)
Recreational Drug Use
Never
Current
Former (Specify substance/frequency)
Caffeine Intake (e.g., cups of coffee/soda per day)
Exercise (e.g., times per week/type)
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Health History Form / Medication History Form
Family History
Heart Disease/Attack: Relative (e.g., Father, Maternal Grandmother)
Cancer: Relative (e.g., Father, Maternal Grandmother)
Diabetes: Relative (e.g., Father, Maternal Grandmother)
High Blood Pressure: Relative (e.g., Father, Maternal Grandmother)
Stroke: Relative (e.g., Father, Maternal Grandmother)
Mental Health Issues: Relative (e.g., Father, Maternal Grandmother)
Review of Systems (ROS) - Optional, but highly recommended for thoroughness
Please check any of the following you are currently experiencing:
General
Fever
Weight Loss
Fatigue
Eyes/Ears/Nose/Throat
Blurry Vision
Hearing Loss
Sinus Congestion
Sore Throat
Gastrointestinal
Nausea/Vomiting
Diarrhea
Constipation
Abdominal Pain
Urinary
Painful Urination
Frequent Urination
Blood in Urine
Skin
Rash
Itching
New Moles/Growths
Psychiatric
Sleep Issues
Excessive Worry
Sadness
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