Medical History Form

Medical History Review of System Form

Date

Name (required)

Your Email (required)

Date of Birth

MarriedSingleDivorcedWidowed

Occupation

# of Children

Tobacco Use
YesNo

How Much?

How Long?

Date Quit

Alcohol Use

Caffeine (Coffee, Tea, Soda)

PAST ILLNESSES OF YOURSELF AND FAMILY:

ALCOHOLISM
YOUYOUR FAMILY

ANEMIA
YOUYOUR FAMILY

ASTHMA
YOUYOUR FAMILY

CANCER/TUMOR
YOUYOUR FAMILY

DIABETES
YOUYOUR FAMILY

DRUG ABUSE
YOUYOUR FAMILY

DEPRESSION
YOUYOUR FAMILY

EPILEPSY/SEIZURES
YOUYOUR FAMILY

GLAUCOMA
YOUYOUR FAMILY

HEART DISEASE
YOUYOUR FAMILY

HIGH BLOOD PRESSURE
YOUYOUR FAMILY

KIDNEY DISEASE
YOUYOUR FAMILY

LIVER DISEASE
YOUYOUR FAMILY

HEPATITIS
YOUYOUR FAMILY

LUNG DISEASE
YOUYOUR FAMILY

MENTAL ILLNESS
YOUYOUR FAMILY

OSTEOARTHRITIS
YOUYOUR FAMILY

OSTEOPOROSIS
YOUYOUR FAMILY

PHLEBITIS
YOUYOUR FAMILY

RHEUMATIC ARTHRITIS
YOUYOUR FAMILY

STROKE
YOUYOUR FAMILY

SUICIDE ATTEMPT
YOUYOUR FAMILY

THYROID DISEASE
YOUYOUR FAMILY

TUBERCULOSIS, TB
YOUYOUR FAMILY

ULCER IN GI TRACT
YOUYOUR FAMILY

VENEREAL DISEASE
YOUYOUR FAMILY

HIGH CHOLESTEROL
YOUYOUR FAMILY

HIGH CHOLESTEROL
YOUYOUR FAMILY

HIV/IMMUNE DX
YOUYOUR FAMILY

OTHER

PAST SURGICAL HISTORY: (Please include dates)

CONSTITUTIONAL

Weight Loss
YesNo

Fatigue
YesNo

Fever
YesNo

Glasses/Contacts
YesNo

Eye Pain
YesNo

Double Vision
YesNo

Cataracts
YesNo

EAR, NOSE, Throat

Difficulty Hearing
YesNo

Ringing in Ears
YesNo

Vertigo
YesNo

Sinus Trouble
YesNo

Nasal Stuffiness
YesNo

Frequent Sore Throat
YesNo

CARDIOVASCULAR

Murmur
YesNo

Chest Pain
YesNo

Palpitations
YesNo

Dizziness
YesNo

Fainting Spells
YesNo

Shortness of Breath
YesNo

Difficulty lying flat
YesNo

SwellingAnkles
YesNo

ENDOCRINE

Loss of Hair
YesNo

Heat/Cold Tolerance
YesNo

RESPIRATORY

Cough
YesNo

Coughing Blood
YesNo

Wheezing
YesNo

Chills
YesNo

GASTROINTESTINAL

Heartburn/Reflux
YesNo

Nausea/Vomiting
YesNo

Constipation
YesNo

Change in BMs
YesNo

Diarrhea
YesNo

Jaundice
YesNo

Abdominal Pain
YesNo

Black or Bloody BM
YesNo

GENITOURINARY

Burning/Frequency
YesNo

Nighttime
YesNo

Blood in Urine
YesNo

Erectile Dysfunction
YesNo

Abnormal Discharge
YesNo

Bladder Leakage
YesNo

ALLERGIC/IMMUNOLOGIC

Hives/Eczema
YesNo

Hay Fever
YesNo

PSYCHIATRIC

Anxiety/Depression
YesNo

Mood Swings
YesNo

Difficulty Sleeping
YesNo

HEMATOLOGY/LYMPH

Easy bruising
YesNo

Gums bleed easily
YesNo

Enlarged Glands
YesNo

MUSCULOSKELETAL

Joint Pain/Swelling
YesNo

Stiffness
YesNo

Muscle Pain
YesNo

Back Pain
YesNo

SKIN
YesNo

Rash/Sores
YesNo

Lesions
YesNo

Itching/Burning
YesNo

NEUROLOGICAL

Loss of strength
YesNo

Numbness
YesNo

Headaches
YesNo

Tremors
YesNo

Memory Loss
YesNo

FEMALES ONLY:

Date of Last Mammogram:
NormalAbnormal

Date of last PAP:
NormalAbnormal

Age On set of Period

Age On set of Menopause

Periods Regular?
YesNo

Number of Pregnancies