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Personal Health History
Please fill out the form below.
Patient Form D - Personal Health History
Today's Date
*
MM slash DD slash YYYY
Patient Name
*
Date of Birth
*
MM slash DD slash YYYY
Preferred Provider
Past Medical History
High Blood Pressure
Diabetes
Heart Attack
Thyroid Disease
Anemia
Heart Disease
High Cholestrol
Asthma
Depression
Hospitalization Checkbox
Hospitalization
Hospitalization. Why?
Other Illness Checkbox
Other Illness
Other Illness. List
Number of Pregnancies
Number of Children
Date of Last Menses
MM slash DD slash YYYY
Past Surgery
Appendix
Tonsils
C-Section
Gallbladder
Hysterectomy
Other Surgeries
Current Medications
No Medications
No Medications
Medication Name
Dose
When Taken
Refills Needed
Yes
No
Medication Name
Dose
When Taken
Refills Needed
Yes
No
Medication Name
Dose
When Taken
Refills Needed
Yes
No
Medication Name
Dose
When Taken
Refills Needed
Yes
No
Medication Name
Dose
When Taken
Refills Needed
Yes
No
Medication Name
Dose
When Taken
Refills Needed
Yes
No
Additional Medications?
Allergies Checkbox
Allergies?
If yes, please explain.
Family History
Heart Disease
High Blood Pressure
Diabetes
Stroke
Cancer
Depression
Work HIstory
Current Occupation
History of exposure to chemicals, fumes or asbestos
Any job related injury?
Yes
No
Are You Disabled?
Yes
No
Why?
Social HIstory
Smoke?
Yes
No
How Much? (packs/day)
Started (years ago)
Quit?
Yes
No
Alcohol?
Yes
No
How many drinks?
Frequency
Daily
Weekly
Illegal Drugs?
Yes
No
History of Sexually Transmitted Disease?
Yes
No
Do you think you have any risk of AIDS?
Yes
No
Continue to Patient Form E - Review of Systems
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