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PATIENT HISTORY FORM

Patient Information


Full Name
DOB
SS#
Patient Email
Patient Mobile
Patient Address
Country
State
City
Reference Physician Name
Physician Email
Physician Phone
Current Condition/Complications
Allergies Medications
Medicine
Reaction
Date Start
Allergies Others

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

Patient Medical History*

  • Diabetes YES NO
  • High Blood Pressure YES NO
  • High Cholesterol YES NO
  • Cancer YES NO
  • Stroke YES NO
  • Heart Issues YES NO
  • Convulsions YES NO
  • Bleeding Tendencies YES NO
  • Recent Infection YES NO
  • Sexually Transmitted Disease YES NO
  • HIV/AIDS YES NO
  • Hepatitis 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, where and when?

Family Medical History

Father
Mother
Brother/Sister
Brother/Sister
Brother/Sister
Son/Daughter
Son/Daughter
Son/Daughter
Other Pertinent Family History(Optional)

Other Health Care Providers Involved in Care