Medical History Template printable pdf download

MEDICAL HISTORY

_________________________________________________

Name:

Date of Birth: _____________

Past Medical History:

_______

Last Pap Smear Date:

Normal? □ No □ Yes Ever had an abnormal Pap Test? □ No □ Yes

__________________________________________________________________________________

_____

Last Mammogram Date:

Normal? □ No □ Yes Ever had an abnormal Mammo Test? □ No □ Yes

Have you had a Bone Density Scan? □ No □ Yes- date & result

_________________________________

Have you had a Colonoscopy? □ No □ Yes- date & result

●Specify/Check Any Problems you have had and the Date of Diagnosis:

_______________________________________________________________________

Pregnancy:

___________________________________________________

Gynecology: (Uterus, Cervix,Ovaries)

_________________________________________________________________________________

STD: □ HPV □ Trich

□ Chlamydia

□ Gonorrhea □ Herpes □ Hepatitis B or C □ HIV □ Syphilis

_____________________________________________________

Breasts: □ Cancer □ Mass □ Biopsy

_____________________________________________

Heart: □ High Blood Pressure

□ Heart Disease

____________________________________________

Digestive Disorders: □ Reflux □ IBS □ Cancer

________________________________________________

Endocrine: □ Diabetes

□ Thyroid Disease

_____________

Blood: □ Anemia □ Blood Transfusion □ Sickle Cell Trait or Disease □ Clotting Disorders

__________________________

Musculoskeletal: □ Arthritis □ Scoliosis □ Osteopenia or Osteoporosis

____________________________________________________

Neurological: □ Migraines □ Seizures

_______________________

Psychiatric: □ Anxiety □ Depression □ Suicide Attempt

□ Eating Disorder

__________________________________________

Respiratory: □ Asthma □ Tuberculosis test positive

_______________________________________________

Skin Disorders: □ Skin Cancer

□ Psoriasis

_____________________________________

Urology: □ Frequent Bladder Infections

□ Kidney Stone

_______________________________________________________________

Seasonal Allergies: □

Surgical History:

□ Tonsillectomy

□ Appendectomy

□ Gallbladder Removal

□ Bladder Surgery

□ Kidney Stones Removed □ Hernia Repair □ Thyroid Surgery □ C-Section □ Sterilization/Tubal Ligation

□ Hysterectomy with Removing Ovaries □ Ovary Cyst Aspirated or Removed □ Cervix Surgery

□ Colposcopy

□ CRYO Freezing

□ Laser or LEEP or Cone of Cervix □ Breast Reduction

□ Breast Augmentation

___________________________________________________________

□ Any Cancer Surgery □ Other:

**Please Include Approximate Dates for Surgeries- if you’ve had any type of hysterectomy state

type AND reason**

Social History:

Alcohol: □ None : □ Occasional □ 1-4 Drinks per week

□ 5 or more per week

_____________________________________________

Tobacco Use: □ No

□ Yes

How many a day:

Education Level: □ High School

□ GED

□ Diploma

□ College

□ Graduate Studies □ Post-Graduate

□ I am a Student now

Exercise: □ None

□ 1-3 x week

□ 4 or more x week

PLEASE TURN PAGE OVER AND FILL OUT BACK SIDE

MEDICAL HISTORY (Page 2)

Medical History Template

Related Articles

Related forms

Related Categories