Comprehensive Patient History Form
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2Sylmar Medical Center, 14124 Foothill Blvd, Suite 100, Sylmar, CA 91342
Comprehensive Patient History Form
Patient Name:_________________________________________________ DOB:___________________ Today’s Date: ________________________
Describe your main problem ___________________________________________________________________________________________________
Where is your problem located?____________________________________________
Have you ever had the following?
How severe is your problem? ______________________________________________
Diabetes……………….
yes
no
Mild > 0 – 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 < Severe
Hypertension………….
Rate the severity of the problem:
yes
no
Cancer…………………
yes
no
How long have you had this problem?________________________________________
Stroke………………….
yes
no
When does this problem occur?_____________________________________________
Heart trouble…………..
yes
no
Arthritis/gout………….
yes
no
Can you attribute the cause of this problem to anything? _________________________
Convulsions……………
yes
no
Bleeding tendency……..
______________________________________________________________________
yes
no
Acute infections………..
yes
no
Are there other symptoms associated with the problem? _________________________
Venereal disease……….
yes
no
STD’s………………….
yes
______________________________________________________________________
no
Hereditary defects……...
yes
no
______________________________________________________________________
What makes this problem worse or better? ____________________________________
______________________________________________________________________
What Medications are you taking?
List previous hospitalizations/Surgeries/Serious Injuries
When?
N/A
________________________________________________
____________________
1)_____________________________
________________________________________________
____________________
2)_____________________________
________________________________________________
____________________
________________________________________________
____________________
3)_____________________________
________________________________________________
____________________
4)_____________________________
5)_____________________________
❏ Noncontributory
6)_____________________________
Patient Social History
7)_____________________________
❏ Single
❏ Married
❏ Separated
❏ Divorced
❏ Widowed
Marital Status:
8)_____________________________
❏ Never
❏ Rarely
❏ Socially
❏ Daily _________________
Use of alcohol:
9)_____________________________
❏ Never
❏ Previously quit ❏ Current packs per day ______
Use of tobacco:
10)____________________________
❏ Never
❏ Type/Frequency_____________________________
Use of Drugs:
11)____________________________
Excessive exposure at home or work to: ❏ Fumes
❏ Dust
❏ Solvents
❏ Noise
12) ___________________________
❏ Chemicals ❏ Smoke ❏ Animal Hair
❏ Noncontributory
Family Medical History
Age
Diseases
If Deceased, Cause of Death
Father
_____
________________________________________________________
____________________________
Mother
_____
________________________________________________________
____________________________
Siblings
_____
________________________________________________________
____________________________
_____
________________________________________________________
____________________________
Spouse
_____
________________________________________________________
____________________________
Children
_____
________________________________________________________
____________________________
_____
________________________________________________________
____________________________
_____
________________________________________________________
____________________________
_____
________________________________________________________
____________________________
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