Health History
PATIENT NAME:        
DATE OF BIRTH:            AGE:  
ARE YOU HERE FOR A ROUTINE EXAM?:    Y    N          SMG Chart #:  
MEDICAL HISTORY - Check if you have had any of the following:
 YN  YN  YN
Anemia Swollen legs/ankles Osteoporosis
Eye problems Varicose veins Broken bones
Severe headache Blood clots Serious injury/MVA
Diabetes Bleeding problems Chemical Dependency
High blood pressure Stomache problems Eating disorder
Heart murmur/disease Bowel problems Severe depression
Asthma Kidney problems Pyschiatric care
Lung disease Liver problems Diethlstilbestrol
exposure
Cancer Gall bladder problems Seizure
Urinary tract infections Thyroid problem Sexually transmitted disease
Breast lump Pelvic infections Allergies [drug, food, etc]
Arthritis        
Comments on Yes answers:
Contraception Method [What do you do to prevent pregnancy?]:
Women:
Date of last menstrual period:         # Pregnancies:         # Births:
List your MEDICATIONS and DOSAGES (include vitamins, herbal remedies & over-the-counter drugs):
List any HOSPITALIZATIONS or SURGERIES you have had:
List your ALLERGIES:
FAMILY HISTORY [father, mother, grandmother, grandfather, brother, sister]:
 YNRelative  YNRelative
Are you Adopted?      
Diabetes Breast Cancer
Stroke Colon Cancer
Heart Disease Ovarian Cancer
High Blood Pressure Other Cancer
High Colesterol Osteoporosis
Anemia Depression
Chronic Lung Disease Anxiety
Bleeding Problems Drug/Alcohol Problems
FAMILY HEALTH - List the present age and health status of each of the following family members.
If desceased, list age and cause of death.
Father: 
Mother: 
Siblings: 
SOCIAL HISTORY
HabitsYN     YN
Smoking Packs/day: Years:  Street Drug Use
Alcohol Drinks/day: Drinks/week:  Regular Exercise
Seat Belt Use       
Personal Profile
Marital Status:     Married     Single     Divorced     Widowed   
Number of Living Children:        Number of People in Household: 
School Completed:     High School     College     Graduate Degree   
Current of Most Recent Job: 
Other
Are you ot have you been sexually/physically mistreated?:     Yes     No   
Do you want to talk to someone about this?:     Yes     No   
REVIEW OF SYSTEMS - Check all of the symptoms that you are currently experiencing:
Constitutional Cardiovascular Hematologic/Lymphatic
Fever Chest Pain Swollen lymph glands
Chills Palpitations/heart fluttering Easy bruising
Sweats/Night sweats Gastrointestinal Easy Bleeding
Fainting Abdominal Pain Endocrine
Weight Change Heartburn, indigestion Excessive thirst, urination
Fatigue Nausea, vomiting Cold or heat intolerance
Seizures Change in appetite Breast
Dizziness Change in bowel habits Breast lumps
Sleeping difficulties Constipation or diarrhea Breast pain
Eyes Dark or bloody stools Breast nipple discharge
Change in vision Rectal bleeding Neurologic/Emotional
Burning/itching eyes Urinary Memory change
Blurred or double vision Painful urination Numbness or tingling
Redness/eye pain Frequent urination Depression
Ears, Nose, Mouth, Throat Urinary urgency,incontinence Anxiety
Change in hearing Blood in urine/dark urine Mood swings
Ear pain Getting up at night to urinate Women
Ringing in ears Musculoskeletal Bleeding/pain with intercourse
Dry mouth Backache, back pain Vaginal discharge or odor
Colds Weakness Pelvic pain
Sore throat Joint pain, stiffness Vulvar/vaginal itching or burning
Hoarseness Muscle cramps Excessive menstrual bleeding
Difficulty swallowing Swelling of hands, feet, ankles Menstrual cramps
Respiratory Leg pain, redness Problems with sexual function
Shortness of breath Skin Men
Chronic cough Change in moles, freckles Pain/lump in testicles
Bloody sputum Rash Difficulty with erections
Wheezing Change in hair growth, loss Problems with sexual function
   Nodules   
Patient Signature
Date
Clinic Use Only:
Weight:Height:Blood Pressure:Pulse:Temperature:
WomenOver 40 Over 50Men Over 50 
Last Pap: Last Mammogram:HRT: Flex Sig:Flex Sig: PSA:
Provider
Date