Your medical history is the cornerstone of your medical
record.
Use it to keep up with your health. Update your medical history often especially as new treatment plans and healthcare issues arise. Copy and complete the following assessment to keep up with your family's health and medical history. MEDICAL HISTORY
NAME____________________________
DATE OF BIRTH_____________________________
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 extra page to list any other medical history
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
