Medical History Form

Patient Information

Patient Name: *

Date of Birth: *

Date Completed: *

Current Medications

Please list ALL medications you are currently taking, including prescription, over-the-counter, vitamins, and supplements.

Medication Name	Dosage/Strength	Frequency	Prescribing Doctor	Reason for Taking

I am not currently taking any medications

Allergies and Adverse Reactions

Drug Allergies (list medication and reaction):

Environmental Allergies (pollen, dust, etc.):

Food Allergies:

No known allergies

Past Medical History

Please check all conditions you have been diagnosed with:

Other Medical Conditions (not listed above):

Surgical History

Previous Surgeries (include type, date, and hospital):

No previous surgeries

Family Medical History

Please indicate if any immediate family members (parents, siblings, children) have had the following conditions:

Heart Disease

Stroke

Diabetes

High Blood Pressure

Cancer

Mental Health Disorders

Kidney Disease

Osteoporosis

Other significant family medical history:

Social History

Tobacco Use:

If current/former, packs per day and years:

Alcohol Use:

Exercise Frequency:

Occupation:

Occupational Hazards/Exposures:

Women's Health (if applicable)

Last menstrual period:

Number of pregnancies:

Number of live births:

Last Pap smear:

Last mammogram:

Current Symptoms or Concerns

Primary reason for today's visit:

Other symptoms or health concerns:

Acknowledgment

I certify that the information provided is accurate and complete to the best of my knowledge. *

I agree to inform the clinic of any changes to this information. *