Your medical history is the cornerstone of your medical record.
Print, fill out, and use it to keep up with your health.
Share it with your healthcare providers, and take a copy with
you when traveling.
MEDICAL HISTORY FORM
NAME__________________________________________
DATE OF BIRTH______________________
SOCIAL SECURITY NUMBER_____________
INSURANCE COMPANY__________________
INSURANCE ID #_______________________
PHONE_____________ FAX___________
ADDRESS__________________________
CITY_________________STATE______
ZIP_______COUNTRY_______________
EMAIL______________________________________________
PAST MEDICAL HISTORY
ALLERGIES______________________________________________________________________________________
_______________________________________________________________________________________________
DRUGREACTIONS________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
DIAGNOSES & MEDICAL CONDITIONS (include year diagnosed)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SURGERY/ OPERATIONS (include year done)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MEDICATIONS (list prescription, over-the-counter, foods, herbs
also write dosage and how often taken)
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PAST MEDICATIONS (list anything you have taken and stopped – note why it was stopped)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
FAMILY HISTORY (list medical conditions in family members – list ages, list if deceased and reason)
MOTHER____AGE________
LIVING: YES___NO____
FATHER____AGE_________
LIVING: YES___NO____
______________________________________________________________________________________________
SISTERS_____AGES_________
LIVING: YES___NO____
_______________________________________________________________________________________________
BROTHERS __AGES_________
LIVING: YES___NO___
_______________________________________________________________________________________________
GRANDMOTHER (Mother's mother) AGE__________LIVING: YES___NO___
_______________________________________________________________________________________________
GRANDMOTHER (Father's mother) AGE__________LIVING: YES__ NO___
_______________________________________________________________________________________________
GRANDFATHER (Mother's father) AGE__________LIVING: YES___NO___
GRANDFATHER (Father's father) AGE___________LIVING: YES___NO___
______________________________________________________________________________________________
OTHER RELATIVES (list any more sisters, brothers, great grandparents, etc. especially those with medical conditions)_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OTHER MEDICAL TREATMENTS (list any other treatments like prayer, massage, chiropractor, exercise, physical therapy, etc.)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SOCIAL HISTORY
Home: lives alone___
lives with family___
lives with friend____
lives in facility_____facility name, address____________________year moved in____________
Marital: Single___Married____Divorced___Widow/Widower_____
Use of cane___ walker___ wheelchair___prosthetic_____
Other___________________________________________
Alcohol consumption:
How many times per day/week/year?________________
How much per drink?____________________________
Cigarette use: Yes___ No___
How many per day?________
At what age did you start?_______
Sexual: Are you active? Yes___No___
Drug use: Yes___ No___
OCCUPATIONS/ JOBS/SCHOOLING
______________________________________________________________________________________________________________
MY MEDICAL NOTES
Use this page to list any other medical history
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