Patient Medical History Form

Patient
First Name
Last Name
MRN
Date of Birth
Age
Notes
Race
White/Caucasian Black or African American Asian Hispanic or Latino American Indian or Alaska Native
Native Hawaiian or
Other Pacific Islanders		 Mixed Other Unknown Patient declines to provide information
Ethnicity
Hispanic or Latino Not Hispanic or Latino Patient declines to provide information
Gender
Male Female Other
Preferred Language
English Italian Spanish
Other
Contact Preference
Cell Phone Home Phone Work Phone
Other
Allergies
Patient has no known allergies Patient has no known drug allergies
Codeine Sulfate Erythromycin Morphine Penicillins Demerol
Iodine Sulfa Novocain Versed Propofol
Aspirin IV Contrast Tape Latex      
Other
Immunizations
None
Hep A Hep B
When: When:
Past or Present Medical Illnesses
None                
Anemia Asthma Atrial Fibrillation Breast Cancer C.O.P.D.
Cirrhosis Colitis Colon Cancer Colon Polyps Congestive Heart Failure
Crohn's Disease Depression Diabetes Melitus Diverticulitis Diverticulosis
Duodenal Ulcer Fatty Liver Frequent Urinary Tract Infections Gallstones Heart Attack - MI
Heart Murmurs Hepatitis A Hepatitis B Hepatitis C High Blood Pressure
High Cholesterol High Triglycerides HIV/AIDS Irregular Heart Beat Irritable Bowel Syndrome
Kidney Disease Kidney Failure Kidney Stones Lactose Intolerance Migraines
Osteoarthritis Pancreatitis Paralysis Parkinsons Pneumonia
Problems with Anesthesia Reflux Rheumatic Fever Rheumatoid Arthritis Seizures
Skin Cancer Sleep Apnea Stomach Ulcer Stroke TB (Tuberculosis)
TB Skin Test Positive Thyroid Disease Ulcerative Colitis Uterine Cancer   
Other

 

Previous Procedures
None                
Appendectomy Breast Surgery C-Section Cardiac Surgery Colon Resection
Colonoscopy Defibrillator EGD/Upper Endoscopy ERCP Gallbladder
Heart Bypass Surgery Heart Stent Heart Valve Replacement Hemorrhoids Hiatal Hernia
Hysterectomy Joint Surgery/Replacement Kidney Liver Liver Biopsy
Obesity Surgery Pacemaker Prostate Sigmoidoscopy Stomach
Thyroid Tonsils Transplant Surgery Tubal Ligation Vasectomy
Other
Social History
Occupation:Number of Children:
Marital Status
Single Married Divorced Separated Widowed
Civil Union Unknown Other    
Alcohol
None                
Daily More than 2 days/week Less than 2 days/week Rarely I quit using alcohol
Tobacco
Smoking Status
Current every day smoker Current some day smoker Former smoker Never smoker
Smoker, current status unknown Unknown if ever smoked        
Cigars Smokeless Chewing Tobacco Cigarettes
Drug Use
None            
I quit using illicit drugs I have never used illicit drugs I use illicit drugs Injection drug use
Exercise
None Light Moderate Strenuous
Family Medical History
No knowledge of family history
No family history of:
Colon Cancer Polyps
Diagnoses
 MotherFatherBrotherSisterGrandmotherGrandfatherDaughterSon
Colitis
Colon Cancer
Colon Polyps
Crohn's Disease
Diabetes
Esophageal Cancer
Gall Bladder Disease
Heart Trouble
Liver Cancer
Ovarian Cancer
Pancreatic Cancer
Stomach Cancer
Ulcer Disease
Ulcerative Colitis
Ulcerative Cancer
Other
Pharmacy Name: