Date: ______________________________________________ Date of birth: ___________________________________________
Name: ______________________________________________ Alias/ Nicknames: _______________________________________
Main Reason for visit: ______________________________________________________________________________________
MEDICAL HISTORY: (note year diagnosed with details)
Single Married Widowed Divorced Separated Occupation: _____________________________________ Years of education/highest degree: ________________ c Cancer (____________________) _______________________________ Tobacco Use:
c Chronic eye/ear/nose disorders _______________________________ Cigarettes: c Never c Quit year ________________ c Current smoker: packs/day ____ # of years _______ Other Tobacco: c pipe c cigar c snuff c chew Are you interested in quitting? c Yes c No Drink caffeine: c Yes c No Cups per day _______
Alcohol Use:
Is your alcohol a concern for you or others? Drug Use:
Have you used any recreational drugs? c Yes c No Have you ever used needles to inject drugs? SURGERIES (major) (Note Year)
c Abdominal ________________
Sexual Activity:
Birth Control method: ______________ c none needed Have you ever had a sexually transmitted disease(s) Other Concerns:
Are you interested in being screened for sexually Weight: Is your weight a concern?
Diet: How do you rate your diet? c Good c Fair c Poor
Exercise: Do you exercise regularly?
Year last done
What kind of exercise?___________________________________ How long (minutes) ___________ How often? ______________ Safety: Is violence at home a concern for you? c Yes c No
Have you completed a living will or
durable power of attorney for health care?
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs:
Name ___________________________________________ HERITAGE
MRN ____________________________________________ PATIENT HISTORY FORM
Date of Birth _____________________________________ ALLERGIES OR REACTIONS TO MEDICINES / FOOD / OTHER AGENTS:
Please note if you have had any of
Check all that apply
the following immunizations
(Note Year)
major illness (Year)
Date of last menstrual period: _____________________ Do you have any of the following problems:
# of pregnancies: ________ # of children: __________ Pap smears: c normal Date_____ c abnormal Date_____ Sexual concerns (getting or keeping an erection) Do you take any of the following:
Progesterone (Provera): c Yes c No c Past Name ___________________________________________ HERITAGE
MRN ____________________________________________ PATIENT HISTORY FORM
Date of Birth _____________________________________



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