MEDICAL HISTORY FORM
Last Name
First Name
Middle Name
Date of Birth
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Sex/Gender
Country of Birth
Permanent Address
City
State
Zip Code
Telephone
Local Address
City
Zip Code
Telephone
Check One:
African American
Hispanic
If English is not your primary language, specify
Asian or Pasific Islander
Native American
primarily spoken language
Caucasian
Alaskan Native
East Indian
Other
Religious Affiliation
In Case of Emergency, Notify:
Name
Relationship
Telephone
Address
City
State
Zip Code
Have You Had:
Yes
No
Yes
No
Yes
No
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
Occupation
Health Status
Age
If no longer living:
Excellent/Average/Poor
Cause of Death
Age at Death
Father
Mother
Brothers
Sisters
Spouse/Partner
Children
HAS ANY FAMILY MEMBER EVER HAD:
(parent, sibling, or grandparent)
Yes
No
Relationship
Yes
No
Relationship
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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March 2023
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