Past Personal Medical History- Yes Or No (Please Circle One)

Health History

Name______Today’s Date______

DOB______Home Phone______

Cell phone______

Past Personal Medical History- yes or no (please circle one)

Anxiety Disorder Y N Eye Problems Y N Liver Disease Y N

Allergies/ Hay fever Y N Fibromyalgia Y N Muscle Problems Y N

Arthritis Y N GERD/ Reflux Y N Neck Pain Y N

Asthma Y N GI Disease Y N Neurological Issues Y N

Back Pain Y N Generalized Pain Y N Orthopedic Issues Y N

Back Pain Chronic Y N Gout Y N Osteoporosis Y N

Bleeding Disorder Y N HIV/ AIDS Y N Prior Colonoscopy Y N

Blood Clots Y N Heart Arrhythmia Y N Prior DEXA Y N

Blood Problems Y N Heart Disease Y N Prior Mammogram Y N

Brain Problems Y N Heart Murmur Y N Pulmonary Embolism Y N

CAD (artery disease) Y N Heart Valve Problem Y N Sinusitis Recurrent Y N

COPD Y N Hiatal Hernia Y N Stroke Y N

Cancer Y N High Cholesterol Y N Colon Polyps Y N

Circulation Problems Y N Hypertension Y N Have Pacemaker Y N

Colitis Y N Hyperthyroidism Y N Insomnia Y N

Depression Y N Hypothyroidism Y N Migraines Y N

Diabetes Y N Irritable Bowel Y N Obesity Y N

Diverticulitis Y N Kidney Disease Y N Osteoarthritis Y N

Ear Problems Y N Kidney Stones Y N Other______

If you indicated a Prior Mammogram please indicate year______.

If you indicated a Prior DEXA, please indicate year______.

If you have a pacemaker, what year was it placed? ______.

Past Surgical History- Circle and specify date of procedure

AAA Repair- Cataract Surgery- LEEP-

Abdominal Surgery- Chest Surgery- Liver Biopsy/ Surgery-

Adenoid Surgery- Cholecystectomy- Lumpectomy-

Amputation- Colectomy- Lung Surgery-

Angioplasty- Colonoscopy- Mastectomy-

Appendectomy- Colposcopy- Orthopedic Surgery-

Arthroscopic Surgery- Ear Tubes- Prostate Surgery-

Back Surgery- EGD- Reconstructive Surgery-

Bladder Surgery- Eye Surgery- Rhinoplasty-

Botox- Fibroid Removal- Septoplasty-

Brain Surgery- Flex Sigmoidoscopy- Skin Biopsy-

Breast Surgery- Gastric Bypass- Skin Cancer-

Bronchoscopy- GU Surgery- Splenectomy-

Bunionectomy- Hemorrhoidectomy- Stents- Cardiac-

CABG- Hernia Repair- Thoracic Surgery-

Caesarian Section- Hysterectomy- Thyroid Surgery-

Cancer Surgery- Joint Replacement- Tonsillectomy-

Carotid Surgery- Kidney Surgery- Tubal Ligation-

Family History- circle & indicate whether grandparent, parent, sibling or aunt/ uncle.

* Maternal Grandmother=MGM, Maternal Grandfather= MGF, Paternal Grandmother= PGM, Paternal Grandfather= PGF

* Mother = M, Father = F, Siblings: Sister= S, Brother = B, Paternal Aunt= PA, Maternal Aunt= MA, Paternal Uncle= PU, Maternal Uncle= MU

Alcohol/Substance Abuse- Diabetes- Lymphoma-

Alzheimer’s Disease- Endocrine Problems- Melanoma-

Aneurysm- Epilepsy/seizures- Obesity-

Asthma- Gallstones- Osteoporosis-

Bipolar- Gout- Prostate Cancer-

Bleeding Disorder- Heart Attack (MI)- Rheumatoid Arthritis-

Breast Cancer- Heart problems- Schizophrenia-

CAD- High Cholesterol- Skin Cancer-

Cancer- Hypertension- Sleep Apnea-

Celiac Disease- Kidney Disease- Stroke-

Colon Cancer- Kidney Stone- Suicide-

Dementia- Leukemia- Other Diagnosis-

Depression- Liver Problems-

Social History- please complete and indicate amount/ frequency

Marital Status______Occupation______

Education______Exercise level______

Special Diet______Cigarette/ Chew Use______

Alcohol intake______Caffeine use______

Illicit Drugs______Wears Seatbelts______

Sunscreen used______Performs Self breast exams______

Allergies- please list all allergies and what type of reaction

*______*______

*______*______

*______*______

Medications- please complete with doses & frequency of use (IE: 1 daily, 1 weekly etc)

*______*______

*______*______

*______*______

*______*______

*______*______

*______*______

*______*______

Thank You