Clear Form
MEDICAL HISTORY FORM
Patient Name: _____________________ DOB: ______/______/_______
Signature: ________________________ Date: _____/______/________
Present Health Concerns: __________________________________________________________________________________________
MEDICATIONS: Please list all prescription and non-prescription medicines, ALLERGIES: List all reactions to medicines, foods and other agents.
vitamins, home remedies, birth control pills, herbs etc.
Medication Name Dose Frequency Allergy Reaction or Side Affect
** If you are on 3 or more medications – please bring them with you to each appointment. **
PERSONAL MEDICAL HISTORY: Please indicate whether you have had any of the following medical problems.
Congenital Heart Disease: Cancer (Malignancy) Hepatitis A, B, or C (specifiy)_______
please specify:_________________ please specify:________________ Date of Last Colonoscopy: ____________
Myocardial Infarction (Heart Attack) Stroke Date of last Tetanus Shot: ____________
Hypertension (High Blood Pressure) Coagulation (Bleeding/Clotting) Date of last HIV Test: ________________
Diabetes Depression/Suicide Attempt Date of Blood Transfusion: ___________
High Cholesterol Alcoholism Other:____________________________
SURGICAL HISTORY: Please list all prior surgeries and dates.
Surgery Date
IMMUNIZATIONS: Please list your most recent immunizations, not including those administered at Lowell General Hospital. Please include your
best estimate of the month and year of each immunization.
Hepatitis A: _________ Measles: ___________ Mumps: ____________ Rubella: ____________ MMR: ______________
Hepatitis B: _________ Pneumovax: ________ Tdap: ______________ Varicella: ___________ Other: _____________
WOMEN’S HEALTHY GYNECOLOGIC/OBSTETRIC HISTORY: (For Women Only)
# of Pregnancies: _____ # of Deliveries: _____ # of Abortions: _____ # of Miscarriages: ____ Age at 1st menses: ___
Frequency of menses: ______ Length of menses: _____ Date of last menses: _______ Date of last mammogram: _______
Do you have any concerns about your period or menopause? □ Yes □ No Please explain: ___________________________________
Have you ever had an abnormal pap smear? □ Yes □ No If circled yes, when was it? _______________________________________
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FAMILY HISTORY: Please indicate with a check (√) who in your family has had the following conditions. In the first column please indicate their
living status. L = Living, D = Deceased, U = Unknown.
High
Living Asthma Diabetes Blood Heart Stroke Heart Cancer Colon Depression Other
Status Pressure Disease Attack (Type) Polyps
Mother
Father
Siblings
Maternal
Grandmother
Maternal
Grandfather
Paternal
Grandmother
Paternal
Grandfather
Other Family Members Information: (please write in)
SOCIAL HISTORY:
Exercise: Drug Use: Alcohol Use
Do you exercise regularly? □ Yes □ No Do you use any recreational drugs? Do you drink alcohol? □ Yes □ No
Tobacco Use: □ Yes □ No If yes, # of drinks per week: __________
□ Current □ Never □ Former: quit on: ______ If yes please list ___________________ What type of alcohol: _______________
*If current # of packs/day ___ # of years ____ If you have used in the past, how long Is alcohol a concern for you or others who
Other Tobacco: □ Pipe □ Cigar □ Snuff □ Chew have you been drug free? ________ surround themselves around you?
Are you interested in quitting? □ No □ Yes Have you ever used needles for IV drug □ Yes □ No
use? □ Yes □ No
SAFETY SOCIOECONOMICS
Do you wear a seatbelt regularly? □ Yes □ No Have you ever been physically or sexually Occupation:_________________________
Do you wear a bike helmet regularly? abused? □ Yes □ No Degree of education completed:_________
□ Yes □ No Do you have a gun in your home? Marital Status: _______________________
Do you feel safe at home? □ Yes □ No □ Yes □ No Spouse/Partner’s Name: _______________
Do you feel safe in your current relationship? Are you a member of a gang? □ Yes □ No Who lives at home with you? ___________
□ Yes □ No Other concerns: _____________________
___________________________________
SEXUALITY Other Services
Are you sexually active? □ Yes □ No Birth Control Method: _________________ Have you had a recent eye exam? □ Yes □ No
Current sex partner(s) are: □ male □ female Have you ever had a sexually transmitted Have you had a recent dental exam?
If sexually active do you practice safe sex? disease? □ Yes □ No □ Yes □ No
□ Yes □ No If yes, please include: __________________ Do you see any other specialists? __________
Other Concerns: _____________________ Are you interested in being screened for ______________________________________
___________________________________ sexually transmitted diseases? □ Yes □ No ______________________________________
EMOTIONS
In the past year, have you had 2 or more weeks during which you felt sad or depressed; or you lost all interest or pleasure in things that
you usually cared about or enjoyed? □ Yes □ No
Have you had 2 or more years in your life when you felt depressed or sad most days, even if you felt okay sometimes? □ Yes □ No
Have you felt depressed or sad much of the time in the past year? □ Yes □ No
Do you ever feel like hurting yourself of others? □ Yes □ No
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REVIEW OF SYSTEMS: Please indicate with a check (√) any current problems you have below.
Constitutional Eyes Musculo-skeletal
Fevers/chills/sweats Changes in vision Muscle/joint pain
Unexplained weight loss/gain Farsighted Arthritis
Fatigue/weakness Nearsighted Other: ______________________
Excessive thirst or urination Other: ______________________ ___________________________
Other: ______________________ ___________________________
___________________________
Neurological
Gastrointestinal Headaches
Cardiovascular Abdominal pain Dizziness/light-headedness
Chest pain/discomfort Blood in bowel movement Numbness
Leg pain with exercise Nausea/vomiting/diarrhea Memory loss
Heart murmur or heart problems Other: ______________________ Loss of coordination
Palpitations ___________________________ Epilepsy or convulsive seizures
Other: ______________________ Other: ______________________
___________________________ ___________________________
Genitourinary
Nighttime urination
Chest Incontinence Psychiatric
Breast lump/discharge Sexual function problems Anxiety/stress
Other: ______________________ Discharge from penis Problems with sleep
___________________________ Other: ______________________ Depression
___________________________ Suicidal ideations
Other: ______________________
Ears/Nose/Throat/Mouth ___________________________
Difficulty hearing/ringing in ears Gynecological
Hay fever/allergies Abnormal vaginal bleeding
Problems with teeth/gums Problems with conceiving Respiratory
Difficulty swallowing Problems with contraception Cough/wheeze
Difficulty with speech Vaginal discharge Difficulty breathing
Other: ______________________ Vaginal odor Asthma
___________________________ Painful intercourse COPD
Other: ______________________ Sleep apnea
___________________________ Other: ______________________
Endocrine ___________________________
Hypothyroid
Hyperthyroid Lymphatic/Blood
Abnormal hormone levels Unexplained lumps Skin
Abnormal blood glucose levels Easy bruising/bleeding Rash or mole change(s)
Other: ______________________ Anemia Psoriasis
___________________________ Other: ______________________ Eczema
___________________________ Other: ______________________
___________________________
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UNIVERSAL MEDICATION FORM Fold this form and keep it in your wallet Date form started: _________________________
Name: ___________________________________ IMMUNIZATION RECORD (Record the date/year of last dose taken, if known)
FLU VACCINE _________________ PNEUMONIA VACCINE ____________________
Address: _________________________________
HEPATITIS VACCINE ____________ TETANUS ____________________
_________________________________________ OTHER: ______________________________________________________________________________________
Phone Number: ___________________________ ALLERGIC TO (Any previous reaction to medications)
Emergency Contact/Phone Numbers: _____________________________________________________________________________________________
_________________________________________ _____________________________________________________________________________________________
_________________________________________ _____________________________________________________________________________________________
Birth Date: _______________________________ _____________________________________________________________________________________________
Organ Donor: qYes qNo _____________________________________________________________________________________________
LIST ALL MEDICINES YOU ARE CURRENTLY TAKING:
Prescription and over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: nitroglycerin).
DATE NAME OF MEDICATION / DOSE DIRECTIONS: Use patient friendly directions. NOTES: DATE STOPPED Notes: Reason for stopping,
(Do not use medical abbreviations.) Reason for taking and doctor name complications, etc.
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UNIVERSAL MEDICATION FORM Fold this form and keep it in your wallet Date form started: _________________________
Name: ___________________________________ IMMUNIZATION RECORD (Record the date/year of last dose taken, if known)
FLU VACCINE _________________ PNEUMONIA VACCINE ____________________
Address: _________________________________
HEPATITIS VACCINE ____________ TETANUS ____________________
_________________________________________ OTHER: ______________________________________________________________________________________
Phone Number: ___________________________ ALLERGIC TO (Any previous reaction to medications)
Emergency Contact/Phone Numbers: _____________________________________________________________________________________________
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Birth Date: _______________________________ _____________________________________________________________________________________________
Organ Donor: qYes qNo _____________________________________________________________________________________________
LIST ALL MEDICINES YOU ARE CURRENTLY TAKING:
Prescription and over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: nitroglycerin).
DATE NAME OF MEDICATION / DOSE DIRECTIONS: Use patient friendly directions. NOTES: DATE STOPPED Notes: Reason for stopping,
(Do not use medical abbreviations.) Reason for taking and doctor name complications, etc.
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UNIVERSAL MEDICATION FORM Fold this form and keep it in your wallet Date form started: _________________________
Name: ___________________________________ IMMUNIZATION RECORD (Record the date/year of last dose taken, if known)
FLU VACCINE _________________ PNEUMONIA VACCINE ____________________
Address: _________________________________
HEPATITIS VACCINE ____________ TETANUS ____________________
_________________________________________ OTHER: ______________________________________________________________________________________
Phone Number: ___________________________ ALLERGIC TO (Any previous reaction to medications)
Emergency Contact/Phone Numbers: _____________________________________________________________________________________________
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Birth Date: _______________________________ _____________________________________________________________________________________________
Organ Donor: qYes qNo _____________________________________________________________________________________________
LIST ALL MEDICINES YOU ARE CURRENTLY TAKING:
Prescription and over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: nitroglycerin).
DATE NAME OF MEDICATION / DOSE DIRECTIONS: Use patient friendly directions. NOTES: DATE STOPPED Notes: Reason for stopping,
(Do not use medical abbreviations.) Reason for taking and doctor name complications, etc.
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UNIVERSAL MEDICATION FORM Fold this form and keep it in your wallet Date form started: _________________________
Name: ___________________________________ IMMUNIZATION RECORD (Record the date/year of last dose taken, if known)
FLU VACCINE _________________ PNEUMONIA VACCINE ____________________
Address: _________________________________
HEPATITIS VACCINE ____________ TETANUS ____________________
_________________________________________ OTHER: ______________________________________________________________________________________
Phone Number: ___________________________ ALLERGIC TO (Any previous reaction to medications)
Emergency Contact/Phone Numbers: _____________________________________________________________________________________________
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Birth Date: _______________________________ _____________________________________________________________________________________________
Organ Donor: qYes qNo _____________________________________________________________________________________________
LIST ALL MEDICINES YOU ARE CURRENTLY TAKING:
Prescription and over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: nitroglycerin).
DATE NAME OF MEDICATION / DOSE DIRECTIONS: Use patient friendly directions. NOTES: DATE STOPPED Notes: Reason for stopping,
(Do not use medical abbreviations.) Reason for taking and doctor name complications, etc.
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UNIVERSAL MEDICATION FORM Fold this form and keep it in your wallet Date form started: _________________________
Name: ___________________________________ IMMUNIZATION RECORD (Record the date/year of last dose taken, if known)
FLU VACCINE _________________ PNEUMONIA VACCINE ____________________
Address: _________________________________
HEPATITIS VACCINE ____________ TETANUS ____________________
_________________________________________ OTHER: ______________________________________________________________________________________
Phone Number: ___________________________ ALLERGIC TO (Any previous reaction to medications)
Emergency Contact/Phone Numbers: _____________________________________________________________________________________________
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Birth Date: _______________________________ _____________________________________________________________________________________________
Organ Donor: qYes qNo _____________________________________________________________________________________________
LIST ALL MEDICINES YOU ARE CURRENTLY TAKING:
Prescription and over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: nitroglycerin).
DATE NAME OF MEDICATION / DOSE DIRECTIONS: Use patient friendly directions. NOTES: DATE STOPPED Notes: Reason for stopping,
(Do not use medical abbreviations.) Reason for taking and doctor name complications, etc.
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