Patient History Form/history Of Present Illness/past Medical, Family & Social History printable pdf download

PATIENT HISTORY FORM

Today’s Date: _______/ _____/ ____Social Security No.: _________________________Date of Birth: ________/ _____/ _____Age: ______

Last Name: ____________________________________First Name:______________________________MI: _____Ht: ______Wt: _______

Chief Complaint: What is the main reason for your visit today? _____________________________________________________________

HISTORY OF PRESENT ILLNESS

Explain Injury or Illness: __________________________________

Date of Accident or Date Symptoms Began:

_____/ _______/ _______

_______________________________________________________

Location of the problem: Rt

Both

_______________________________________________________

Describe the symptoms you are having: ____________________

Was this a work related accident?

Yes

_______________________________________________________

Was this an auto accident?

Yes

_______________________________________________________

Recreational or school athletic injury?

Yes

Accident in your home?

Yes

_______________________________________________________

Accident other than above?

Yes

Is anything else occurring at the same time?

Explain: _______________________________________________

� Yes � No If yes, please explain.

Are you currently working?

Yes

Nausea

Rash

Headaches

Fatigue

Wt Loss/Gain

If yes, are you working:

full duty

limited duty

Diarrhea

Fever

Bloating

Bleeding

List any other doctors you have seen for this problem:

Other __________________________________________________

_______________________________________________________

How long does the problem last?

_______________________________________________________

30 minutes

1 hour

It is always there

List any previous tests or procedures for this problem:

Other __________________________________________________

_______________________________________________________

Is the problem constant or variable?

_______________________________________________________

Dull then Sharp

Very sharp then leaves

Always there

_______________________________________________________

Other:__________________________________________________

Does anything help or make the problem worse?

Does the problem interfere with your normal functions?

Moving around

Standing up

Lying on my side

� Yes � No If yes, please explain

Other __________________________________________________

_______________________________________________________

PAST MEDICAL, FAMILY & SOCIAL HISTORY

List any personal illness:

List any surgeries and date occurred:

Check Current Immunizations:

_________________________________

___________________________________

 Flu

Approx. Date

_________________________________

___________________________________

 Tetanus

Approx. Date

_________________________________

___________________________________

 Pneumonia

Approx. Date

_________________________________

___________________________________

List all serious illnesses in your immediate

Do you have any drug allergies? Yes No (If Yes, please explain)

family. (Example: diabetes, tuberculosis,

_________________________________

___________________________________

breast cancer, heart disease, etc.):

_________________________________

___________________________________

Relation

Please list all medications you are currently taking:

___________________ _____________

_________________________________

___________________________________

___________________ _____________

_________________________________

___________________________________

___________________ _____________

_________________________________

___________________________________

___________________ _____________

_________________________________

___________________________________

___________________ _____________

_________________________________

___________________________________

Do/did you smoke?

� Yes

� No

Do/did you drink? � Yes � No

Do you exercise regularly? � Yes � No

If yes, how much? ___________________

If yes, how much? __________________

If yes, how much? _____________________

If yes, how long? ____________________

Are you right or left handed? Rt. Lt

If age 55 or older, have you ever had a

Bone Density Test? � Yes

� No

AZ-94

Patient History Form/history Of Present Illness/past Medical, Family & Social History

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