Medical History

Name: Date: Email:

Have you had any serious or chronic illnesses?: Yes No
If yes, describe and age it began:

Have you had any surgeries?: Yes No
If yes, describe and date of surgery:

Have you been hospitalized for any reason other than surgery?: Yes No
If yes:

Approximate Year	Reason
1.
2.
3.

Are you taking any medications, including over the counter or herbal, on an onging basis?: Yes No
If yes, please list them:

Medication	Dose	Frequency	Condition begin treated/Symptoms
1.
2.
3.
4.
5.
6.
7.
8.

Have you had any allergies or adverse reactions to medication?: Yes No
If yes, please list the medication and the type of reaction:

Medication	Type of Reaction

Do you have a family history (mother, father, brothers or sisters) of cancer, heart disease, diabetes or other serious illnesses?: Yes No

Relative	Age of Onset	Disease
1.
2.
3.
4.
5.
6.
7.
8.

Do you use any of the following tobacco products?

Cigarettes?	Yes	No
Chew?	Yes	No
Pipe?	Yes	No
Cigars?	Yes	No

If yes, how much?

Have you used tobacco products in the past?

Yes

If yes, how many years did you use tobacco?

Do you use alcohol? Never Occasionally 1-2 drinks/day More than 2/day

How many days per week do you exercise?

What type of exercise?
Do you wear your seatbelt? Never Usually Always

Have you had your cholesterol checked? Yes No
When?
Result?

When was you last tetanus shot?

If you are a female over age 21, when was your last pap smear?

If you are a female over age 40, when was your last mammogram?

If you are over age 50, when was your last colon exam?

If you are over age 65, have you been vaccinated for pneumonia? Yes No

Job/Profession	Hobbies/Interests

Are you: married single divorced other
Number of Children?
Number of Pregnancy's?

What else would you like to the doctor to know about yourself?

How did you select this office for your care?

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