MEDICAL HISTORY FORM
Last NameFirst NameMiddle Name
Date of Birth
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Sex/GenderCountry of Birth
Permanent Address
CityStateZip CodeTelephone
Local Address
CityZip CodeTelephone
Check One:
African AmericanHispanicIf English is not your primary language, specify
Asian or Pasific IslanderNative Americanprimarily spoken language
CaucasianAlaskan Native
East IndianOtherReligious Affiliation
In Case of Emergency, Notify:
NameRelationshipTelephone
Address
CityStateZip Code
Have You Had:YesNoYesNoYesNo
Head Injury with Unconsciousness
Sexually Transmitted Disease
Counseling/Mental Health Treatment
Asthma
Malaria
Bleeding/Blood Disorder
Recurrent Headaches
Chicken Pox
Tuberculosis
Seizure Disorder
Scarlet Fever
Spinal Cord Disruption
Hearing Loss
Hay Fever
Eating Disorder
Recurrent Ear Infections
Rheumatic Fever
Recreational Drug Use
Visual Problem (other than glasses)
High Cholesterol
Tobacco Use
Thyroid Problem
Hepatitis A,B, or C
Alcohol Use
Heart Problem/Murmur
Diabetes
# times per week
Kidney/Urinary Tract Problem
High Blood Pressure
amount per session
Gynecology Problem(s)
Digestive Tract Problem
Recent Weight Change
Cancer/Tumor/Cyst
Exercise: times per week
Operations / Dates:Chronic Health Problems:Alternative Medicine Practices:
Allergies(write NONE if none)
to Drugs/Medications:Other Allergies (i.e., environmental):Routine Medications Taken:
Family Member OccupationHealth StatusAgeIf no longer living:
Excellent/Average/Poor Cause of DeathAge at Death
Father
Mother
Brothers
Sisters
Spouse/Partner
Children
HAS ANY FAMILY MEMBER EVER HAD:
(parent, sibling, or grandparent)YesNoRelationshipYesNoRelationship
Tuberculosis
Asthma
Drug/Alcohol Abuse
Thyroid Disease
Diabetes
Seizure Disorder
Kidney Disease
Blood Disorder
Heart Disease
Cancer
High Blood Pressure
Stroke
Arthritis
Obesity
Stomach Disease
Other
High Cholesterol
OTHER CONCERNS/INFORMATION:
Date
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