MEDICAL HISTORY


Reason for today's visit: ___________________________________
Present Medications: _____________________________________
ALLERGIES TO MEDICATION: ____________________________________________________________
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Allergies (E.G., ITCHIMESS OR HIVES) ______________________________________________________
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OTHER PHYSICIANS CURRENTLY THEATING YOU: _________________________________________
 PHONE NUMBER  _______________
PREVIOUS OR OTHER MEDICAL PROBLEMS: _______________________________________________
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LIST ANY PREVIOUS SURGERIES OR HOSPITALIZATIONS (INCLUDE NUMBER OF MISCARRIAGES AND LIVE BIRTHS): ___________________________________________________________________________
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FEMALES ONLY: ABE YOU PREGNANT, PLANNING A PREGNANCY OR NURSING A CHILD?  YES
DO YOU SMOKE?   NO   YES   CIGARETTES   PIPE   CIGARS   NO.OF YEARS: ____________________
HOW MUCH: ____________________________________________________________________________
INTERESTED IN STOPPING   YES    NO  DO YOU REGULARLY DRINK ALCOHOL?   YES   NO    HOW
MANY OUNCES/BEERS PER DAY? ____________________________________________________

DO YOU REGULARLY DRINK COFFEE?   YES    NO  HOW MANY CUPS PER DAY?
ARE YOU UNDER A LOT OF PRESSURE AT WORK?    No    YES
PLEASE DESCRIBE: _______________________________________________________________________
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Personal Medical History: _____________________________________________________________________
Have you ever had any of the following (check all that apply)

 [ ]     CHEST PAIN            [ ]  ASTHMA                               [ ]  KIDNEY DISEASE
 [ ]     HYPERTENSION     [ ]  DIZZY SPELLS                      [ ]  SHORTNESS OF BREATH
 [ ]     HEPATITIS               [ ]  CANCER                                [ ]  TUBERCULOSIS
 [ ]     STROKE                   [ ]  DIABETES                              [ ]  ULCERS
 [ ]     HEAD ACHE            [ ]  ARTHRITIS                             [ ]  SKIN DISORDERS
 [ ]     GLAUCOMA            [ ]  HEARING LOSS                    [ ]  HEART ATTACK
 [ ]     ALLERGIES              [ ]  CATARACTS                         [ ]  DIGESTIVE PROBLEMS
 [ ]     BLOOD IN STOOL  [ ] URINARY TRACT                  [ ]  OTHER

PREVIOUS PSYCHOLOGICAL CARE                                  FAMILY HISTORY INFORMATION


DATE                      OUTCOME                                                                     FATHER’S  MOTHER’S
__________________________________                  FATHER  MOTHER  PARENTS   PARENTS    SIBLINGS
__________________________________ALCOHOL         []                []                []                []                    []
__________________________________DRUGS               []                []                []                []                    []
__________________________________PRE. MEDS        []                []                []                []                    []
__________________________________DEPRESSION    []                []                []                []                    []
                                                                    GAMBLING       []                []                []                []                    []
                                                            LEGAL SYSTEM       []                []                []                []                    []
                                                                    ANXIETY          []                []                 []                []                    []
                                                                    PANIC               []                []                 []                []                    []