CONFIDENTIAL HEALTH HISTORY
Name: Date:
Birthdate: Age: Date of last physical examination: Occupation:
Reason for visit
today:
MEDICATIONS List all medications you are currently taking ALLERGIES List all allergies
SYMPTOMS Check {P} symptoms you currently have had in the past year.
GENERAL GASTROINTESTINAL EYE, EAR, NOSE, MEN only
THROAT
£ Chills £ Appetite poor £ Bleeding gums £ Breast lump
£ Depression £ Bloating £ Blurred vision £ Erection difficulties
£ Dizziness £ Bowel changes £ Crossed eyes £ Lump in testicles
£ Fainting £ Constipation £ Difficulty swallowing £ Penis discharge
£ Fever £ Diarrhea £ Double vision £ Sore on penis
£ Forgetfulness £ Excessive hunger £ Earache £ Other
£ Headache £ Excessive thirst £ Ear discharge WOMEN only
£ Loss of sleep £ Gas £ Hay fever £ Abnormal Pap Smear
£ Loss of weight £ Hemorrhoids £ Hoarseness £ Bleeding between periods
£ Nervousness £ Indigestion £ Loss of hearing £ Breast lump
£ Numbness £ Nausea £ Nosebleeds £ Extreme menstrual pain
£ Sweats £ Rectal bleeding £ Persistent cough £ Hot flashes
MUSCLE/JOINT/BONE £ Stomach pain £ Ringing in ears £ Nipple discharge
Pain, weakness, numbness in: £ Vomiting £ Sinus problems £ Painful intercourse
£ Arms £ Hips £ Vomiting blood £ Vision – Flashes £ Vaginal discharge
£ Back £ Legs CARDIOVASCULAR £ Vision – Halos £ Other
£ Feet £ Neck £ Chest pain SKIN
£ Hands £ Shoulders £ High blood pressure £ Bruise easily Date of last
GENITO-URINARY £ Irregular heart beat £ Hives menstrual periodDate of last
£ Blood in urine £ Low blood pressure £ Itching Pap Smear
£ Frequent urination £ Poor circulation £ Change in moles Have you had
£ Lack of bladder control £ Rapid heart beat £ Rash a mammogram? £ Painful urination £
Are you pregnant?
Swelling of ankles £ Scars
Number of children
£ Varicose veins £ Sores that won’t heal
MEDICAL HISTORY Check {P} the medical conditions you have or have had in the past.
£ AIDS £ Chemical dependency £ Herpes £ Polio
£ Alcoholism £ Chicken Pox £ High Cholesterol £ Prostate Problem
£ Anemia £ Diabetes £ HIV Positive £ Psychiatric Care
£ Anorexia £ Emphysema £ Kidney Disease £ Rheumatic Fever
£ Appendicitis £ Epilepsy £ Liver Disease £ Scarlet Fever
£ Arthritis £ Gall Bladder Disease £ Measles £ Stroke
£ Asthma £ Glaucoma £ Migraine Headaches £ Suicide Attempt
£ Bleeding Disorders £ Goiter £ Miscarriage £ Thyroid Problems
£ Breast Lump £ Gonorrhea £ Mononucleosis £ Tonsilitis
£ Bronchitis £ Gout £ Multiple Sclerosis £ Tuberculosis
£ Bulimia £ Heart Disease £ Mumps £ Typhoid Fever
£ Cancer £ Hepatitis £ Pacemaker £ Ulcers
£ Cataracts £ Hernia £ Pneumonia £ Vaginal Infections
£ Venereal Disease
CONFIDENTIAL HEALTH HISTORY
HOSPITALIZATIONS
Year Hospital Reason for Hospitalization and Outcome
Have you ever had a blood transfusion? £ Yes £ No
If yes, please give approximate dates:
OCCUPATIONAL CONCERNS HEALTH HABITS Check {P} which PREGNANCY HISTORY
Check {P} if your work exposes you substances you use and indicate how much Year of Sex of Complications if any
to the following: you use per day/week. Birth Birth
£ Stress £ Caffeine
£ Hazardous Substances £ Tobacco
£ Heavy Lifting £ Drugs
£ Other £ Alcohol
SERIOUS ILLNESS/INJURIES DATE OUTCOME
FAMILY HISTORY Fill in health information about your family.
State of Age of Cause of Death Check {P} if your blood relatives had any of the following
Relation Age Health Death Disease Relationship to you
Father £ Arthritis, Gout
Mother £ Asthma, Hay Fever
Brothers £ Cancer
£ Chemical Dependency
£ Diabetes
£ Heart Disease, Strokes
Sisters £ High Blood Pressure
£ Kidney Disease
£ Tuberculosis
£ Other
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of
his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Signature Date
Reviewed By Date
