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