MEDICAL HISTORY FORM

NAME_________________________________________

DATE OF BIRTH________________________________

SOCIAL SECURITY NUMBER_____________________

INSURANCE COMPANY__________________________
INSURANCE ID #________________________________

PHONE__________________FAX__________________

ADDRESS______________________________________

CITY_________________STATE________ZIP________

EMAIL_________________________________________

PAST MEDICAL HISTORY

ALLERGIES_____________________________________________

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DRUG REACTIONS______________________________________________
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DIAGNOSES & MEDICAL CONDITIONS (include year diagnosed)
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SURGERY/ OPERATIONS (include year done)
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MEDICATIONS (list prescription, over-the-counter, foods, herbs – also write dosage and how often taken)
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PAST MEDICATIONS (list anything you have taken and stopped – note why it was stopped)
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FAMILY HISTORY (list medical conditions in family members – list ages, list if deceased and reason)

MOTHER____AGE________LIVING: YES___NO___
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FATHER____AGE_________LIVING: YES___NO____
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SISTER_____AGE_________LIVING: YES___NO____
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SISTER_____AGE_________LIVING: YES___NO____
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BROTHER__AGE_________LIVING: YES___NO___
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BROTHER__AGE__________LIVING: YES___NO___
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GRANDMOTHER (Mother’s mother)AGE__________LIVING:YES___NO___
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GRANDMOTHER (Father’s mother) 

AGE__________LIVING: YES__ NO___
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GRANDFATHER (Mother’s father)    AGE__________
LIVING: YES___NO___
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GRANDFATHER (Father’s father)    AGE___________
LIVING: YES___NO___
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OTHER RELATIVES (list any more sisters, brothers, great grandparents, etc. especially those with medical conditions)__________________________________________________________

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OTHER MEDICAL TREATMENTS (list any other treatments like prayer, massage, chiropractor, exercise, physical therapy, etc.)_________________________________________________________
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SOCIAL HISTORY

Home:  lives alone___ 
             lives with family___
             lives with friend____
             lives in facility_____name,address____________________

Marital: Single___Married____Divorced___ Widowed____

Use of cane___ walker___ wheelchair___prosthetic_____
Other___________________________________________

Alcohol consumption: 
   How many times per day/week/year?________________
   How much per drink?____________________________

Cigarette use: Yes___ No___
   How many per day?________
   At what age did you start?_______

Sexual:  Are you active? Yes___No___

Drug use: Yes___ No___

OCCUPATION/ JOBS/SCHOOLING_________________________________________
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MY MEDICAL NOTES (Use this section to list any other medical history, questions. etc.)