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Patient History Form

Reason for Visit


Patient Name
Referring Physician
Current condition/compliant
Allergies Medications
Medicine
Reaction
Date Start
Allergies Medications

OFFICE USE ONLY

RUE(BP)mmHg
(Height)inches
LUE(BP)mmHg
(Weight)lbs
(Heart Rate) bpm
(Temp) °F
(Resp. Rate)per/min
(O2 Sat)%
History of present illness
Previous Hospital Admissions/Surgeries/Serious Injuries
Date/S
Name Of Hospital
Current Medications(Dose and Frequency)

Patient Medical History

Diabetes
YES NO
High Blood Pressure
YES NO
High Chalestral
YES NO
Cancer
YES NO
Stroke
YES NO
Heart Issues
YES NO
Convulsions
YES NO
Bleeding tendancy
YES NO
Recent Infection
YES NO
Sexually Transmitted Disease
YES NO
HIV/AIDS
YES NO
Hepatits
YES NO
Tuberculosis
YES NO
Family history of cancer
YES NO
Other History

Patient Social History

Marital Status
Single Married Seperated Divorced Widowed
Use of Alcohol
Never Rarely Moderate Daily
Use of Tobacco
Never Previously,but quit
Current Packs/day
Use of Drugs
Never
Type frequncy
Travel Outside Country
NO
YES, If yes then where

Family Medical History

Age
Diseases
Cause of Death
Father
Mother
Sibling
Sibling
Sibling
Child
Child
Child
Maternal Grand Parent
Parental Grand Parent
Other Health Care Providers Involved in Care
Name
Speciality
Office Phone
Office Fax