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Medical History Form

A medical history form is filled out to provide a patient’s current medical record and history. It helps medical professionals determine the best possible medical treatment for patients by determining past, and possibly correlated, medical conditions. Maintaining the security of data collected through medical history forms is crucial for healthcare institutions to stay compliant with legal requirements. Medical history forms should be filled out using a SOAP note checklist.

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Medical History
General Information
Name
Birth date
Age
Sex
Contact phone numbers
Briefly describe your present symptoms
Please list other physicians you have seen in the last 12 months, and for what reason.
Current Medications
Drug allergies?
To what:
Medications that you are now taking. Include non-prescription medications & vitamins or supplements.
Medical History
Do you now or have you ever had:
Diabetes
High blood pressure
High cholesterol
Hypothyroidism
Goiter
Cancer
Type:
Leukemia
Psoriasis
Psychiatric condition
Type:
Angina
Heart problems
Heart murmur
Pneumonia
Pulmonary embolism
Asthma
Emphysema
Stroke
Epilepsy (seizures)
Cataracts
Glaucoma
Kidney disease
Kidney stones
Crohn’s disease
Colitis
Anemia
Jaundice
Hepatitis
Stomach or peptic ulcer
Varicose veins
Environmental allergies
Blood clots
Serious trauma
Sexually transmitted infection
Other:
Personal History
Childhood Illness
Immunizations?
Tetanus
Date of immunization
Pneumonia
Date of immunization
Hepatitis A
Date of immunization
Hepatitis B
Date of immunization
Chickenpox
Date of immunization
Influenza
Date of immunization
MMR (Measles, Mumps, Rubella)
Date of immunization
Meningococcal
Date of immunization
Any surgeries?
Please provide the year/reason/hospital
Have you ever had a blood transfusion?
Where were you born & raised?
What is your highest education?
Marital status
What is your current or past occupation?
Family History
Family history is:
Please indicate if your family has a history of the following: (include only parents, grandparents, siblings, and children)
Alcohol Abuse
Anemia
Anesthetic Complication
Arthritis
Asthma
Bladder Problems
Bleeding Disease
Breast Cancer
Colon Cancer
Depression
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Leukemia
Lung/Respiratory Disease
Migraines
Osteoporosis
Other Cancer
Rectal Cancer
Seizures/Convulsions
Severe Allergy
Stroke/CVA of the Brain
Thyroid Problems
Mother, Grandmother, or Sister developed heart disease before the age of 65
Father, Grandfather, or Brother developed heart disease before the age of 55
NONE of the Above
Review of Systems
Please indicate with a check (√) any current problems you have below.
Constitutional
Fevers/chills/sweats
Unexplained weight loss/gain
Fatigue/weakness
Excessive thirst or urination
Other
Please describe other
Cardiovascular
Chest pain/discomfort
Leg pain with exercise
Heart murmur or heart problems
Palpitations
Other
Please describe other
Chest
Breast lump/discharge
Other
Please describe other
Ears/Nose/Throat/Mouth
Difficulty hearing/ringing in ears
Hay fever/allergies
Problems with teeth/gums
Difficulty swallowing
Difficulty with speech
Other
Please describe other
Endocrine
Hypothyroid
Hyperthyroid
Abnormal hormone levels
Abnormal blood glucose levels
Other
Please describe other
Eyes
Changes in vision
Farsighted
Nearsighted
Other
Please describe other
Gastrointestinal
Abdominal pain
Blood in bowel movement
Nausea/vomiting/diarrhea
Other
Please describe other
Genitourinary
Nighttime urination
Incontinence
Sexual function problems
Discharge from penis
Other
Please describe other
Gynecological
Abnormal vaginal bleeding
Problems with conceiving
Problems with contraception
Vaginal discharge
Vaginal odor
Painful intercourse
Other
Please describe other
Lymphatic/Blood
Unexplained lumps
Easy bruising/bleeding
Anemia
Other
Please describe other
Musculo-skeletal
Muscle/joint pain
Arthritis
Other
Please describe other
Neurological
Headaches
Dizziness/light-headedness
Numbness
Memory loss
Loss of coordination
Epilepsy or convulsive seizures
Other
Please describe other
Psychiatric
Anxiety/stress
Problems with sleep
Depression
Suicidal ideations
Other
Please describe other
Respiratory
Cough/wheeze
Difficulty breathing
Asthma
COPD
Sleep apnea
Other
Please describe other
Skin
Rash or mole change(s)
Psoriasis
Eczema
Other
Please describe other
Sexual History
Have you ever been sexually active?
Are you currently sexually active?
Complete the following questions if you are sexually active.
Are you currently having sexual relations with one partner or multiple partners?
Number of partners in last year
Are you in a monogamous relationship?
Are/Is your sexual partner(s)
Do you and your partner use contraceptive and/or protective methods?
Have you ever had a sexually transmitted illness (STI) (i.e. HPV, Herpes, Chlamydia, Gonorrhea or other)?
List STI:
Treated
Women's Reproductive History
Age of first period
Number of pregnancies
Number of miscarriages
Number of abortions
Do you have regular periods?
Have you reached menopause?
At what age?
Patient Name and Signature:
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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