Personal Medical History

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NEW PATIENT

PERSONAL MEDICAL HISTORY

Ihave a personal history of the following problems: PCP New Patient Med history, Rev. 03/2016

Arthritis: what type? / High Cholesterol
Blood Disorder: what kind? / Kidney Problems
Cancer: what kind? / Liver Problems, Hepatitis
Diabetes / Lung Problems/asthma
Ears/Nose/Throat: specify / Musculoskeletal problems
Gastrointestinal: what type? / Neurology: Stroke/Seizures
Genitourinary/Prostate / Psychiatric problems
Heart Problems / Sexually Transmitted Diseases
High Blood Pressure / Thyroid abnormality
other:

I have had the following surgeries:

If you have had surgery on one or more of these body areas, indicate what type of surgery:

□ Head/Neck/Breast surgery: □ Heart/Lung surgery:

□ Abdominal/Pelvic surgery: ______□ Spine Surgery:

□ Bone/Joint surgery: □ other:

Have you ever been hospitalized for any sickness not surgery related □Yes □No

Date: Hospital: Reason:

Medications / Allergies
Do you have any siblings □ Yes □ No
# of Brothers:
# of Sisters:
Occupation & Employer:
Circle Current Marital Status / Single / Married / Partnered / Separated / Divorced / Widowed
Current Partner Status / Male / Female / Both / Other / None

Family History:

Please See Attached form for Family History.

I certify that all the information is accurate:______Date:______

Patient’s signature (or patient’s representative)

Please See Backside →

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I have had the following procedures:

Test / Date or Year / Results (normal/abnormal)
Colonoscopy
Hemoccult (test for blood in stool)
Mammogram
DEXA (bone density test for osteoporosis)
Cholesterol blood test
Diabetes blood test
Men only: PSA (prostate blood test)
Men only: AAA screen (abdominal aorta ultrasound)
Women only: Pap smear

I have had the following Vaccines: Tobacco use:

Vaccine / Date/Year Administered
Tetanus
Pertussis
Influenza (flu)
Pneumonia
Hepatitis A
Hepatitis B
Meningitis
HPV
shingles
Cigarettes:
□ Never a Smoker
□ Current every day smoker
□ Former Smoker
Packs Per Day: □ ½ □ 1 □ 1 ½ □ 2 □2 ½ □ 3+
Other:
□ Cigars □ Chew or Snuff
□ Exposure to smoke in household

These are the specialists currently involved in my care (if any):

Opthalmologist:______

Cardiologist:______

Pulmonologist:______

Dermatologist:______

Oncologist:______

Orthopedist:______

Ear/Nose/Throat:______

Urologist:______

Neurologist:______

Gynecologist:______

Gastroenterologist:______

For Women only:

Have you ever had an abnormal Pap smear? Yes_____ No_____ If so, when and what (if any) procedures were done?______

Have you ever had an abnormal mammogram? Yes_____ No_____ If so, when and what (if any) procedures were done?______

Have you had a hysterectomy? Yes_____ No_____ If so, what was the reason?______

Are you still menstruating? Yes_____ No_____ If no, how old were you when you stopped?______

I certify that all the information is accurate:______Date:______

Patient’s signature (or patient’s representative)

PCP New Patient Med history, Rev. 3/2016

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