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Patient Health History

Name: ______________________________________________ Date: ______________

SSN:________________________________________________ DOB: _____________

Chief Complaint: What is the reason for your visit today? (Please describe problem in detail including
history of present illness): _______________________________________________________________

Past Medical History: Please check all that apply to you:

q Arthritis q Epilepsy/seizures q Psychiatric disease
q Cancer q Heart problems q Stroke
q Depression q Heart surgery q Thyroid
q Diabetes q High blood pressure q None

Previous Surgeries: Please list past surgeries with approximate date: ___________________________

Serious Injury: Please describe any serious injuries you have had: ______________________________

Medications: Please list any medications you are taking with dose and frequency:
Drug Dose/Frequency

Allergies: please list any allergies that you have _____________________________________________


Social History:
Do you drink alcohol? qYes qNo If yes, how much/week? ___________________________________
Do you smoke? qYes qNo If yes, how many cigarettes/day? __________________________________
Do you consume caffeine? qYes qNo If yes, how many cups/week? ____________________________
Do you use recreation drugs? qYes qNo If yes, what type and frequency? _______________________
Are you on a special diet? qYes qNo If yes, please describe? ________________________________

Family History: Do you know of any blood relative who has or had:
q Asthma q Headaches q Multiple Sclerosis
q Aneurysm q Heart Problems q Psychiatric Disease
q Brain Tumor q High blood pressure q Stroke
q Cancer, Type: q Kidney disease q Thyroid
q Diabetes q Lung Disease q None
q Epilepsy/Seizures q Migraine

Patient Health History

As you review the following list, please check any problems or conditions, that you are experiencing or
have experienced. If you do not have any of the problems listed in the section please check none.

General Health Genitourinary q Neuropathy

q Good general health q Blood in urine q Numbness or tingling
q Recent weight change q Female: irregular periods q Paralysis
q Loss of appetite q Female: #pregnancies_____ q Stroke
q Fatigue #miscarriages______ q Tremors
q Fever/chills q Female: vaginal discharge q Weakness
q Kidney stones q Other: _________________
Allergy q Male: prostate disease q None
q Drug allergies q Male: testicle pain Are you? q right handed
q Food allergies q Painful or burning urination q left handed
q Hay fever q Sexual difficulty q Both
q Other: _________________ q Sexually transmitted disease
q None q Urgency with urination Psychiatric
q Urine retention/ q Depression
Ears, Nose, Mouth, Throat incontinence q Anxiety
q Difficulty swallowing q Other: _________________ q Eating disorder
q Earaches q None q Other: _________________
q Loss of hearing/deafness q None
q Loss of smell Heart and Lungs
q Loss of taste q Pain in chest Pulmonary
q Painful chewing q High blood pressure q Asthma
q Ringing in ears q High cholesterol q Blood in cough
q Sinus infection q Irregular heart beat q Cancer
q Sores in mouth q Other: _________________ q Chronic or frequent cough
q None q None q Emphysema
q Other: _________________ q Pneumonia
Muscles/Joints/Bones q Shortness of breath
Eyes q Back pain q Other: _________________
q Blind spots q Difficulty walking q None
q Blurred vision q Joint pain
q Double vision q Joint stiffness or swelling Skin
q Loss of vision q Muscle pain or tenderness q Rash or itching
q Glaucoma q Neck pain q Sun sensitivity
q Injury q None q Hair loss
q Pain q Color changes
q Other: _________________ Neurological q Other: _________________
q None q Balance trouble q None
q Black outs/loss of
Gastrointestinal consciousness Sleep
q Blood in stools q Difficulty speaking q Snoring
q Increasing constipation q Difficulty walking q Sleepwalking
q Nausea q Facial drooping q Nightmares
q Painful bowel movements q Headaches Do you sleep well? qYes qNo
q Persistent diarrhea q Injury to the brain or spine Do you feel rested when you
q Stomach or abdominal pain q Light-headed or dizziness wake? qYes qNo
q Ulcer q Memory loss Do you fall asleep during the
q Vomiting q Mental Confusion day? qYes qNo
q Other: _________________ q Migraines
q None q Mini stroke

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