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Fillable Form Medical History

A health record is a confidential collection of relevant information from the health history of a person, including all past and present medical problems, disorders and procedures, with focus on the particular incidents occurring during the current episode of care impact the patient.

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What is a Medical History form?

A medical history form is a record of information about your health. Hospitals and doctors review your health history to be able to determine the best treatment for you. A medical history form includes information about your allergies, illnesses, past surgeries, vaccinations, and results of physical exams and tests.

How to fill out a Medical History form?

Page 1

NOTES

The answers and information that you provide on this form will help your doctors understand your medical concerns and conditions better.

If there are questions that make you feel uncomfortable, feel free not to answer them.

If you cannot remember specific details, best estimates will do.

Name

Enter your full name.

Phone

Enter your home and work number.

Street

Enter the street of your residence.

City

Enter the city of your address.

State

Enter your state of residence.

Zip

Enter the zip code.

Age

Enter your age.

Height

Enter your height in feet.

Weight

Enter your weight in pounds.

Occupation

Enter your occupation.

Gender

Enter your gender. You may choose M for Male and F for Female.

Date of Birth

Enter your date of birth.

Place of birth

Enter the place or hospital of your birth.

Marital Status

Enter your marital status.

Family Physician

Provide the name of your family physician.

Social Security No.

Enter your social security number.

Emergency Contact

Provide the name of your emergency contact.

Telephone number

Provide the telephone number of your emergency contact.

Reference person

Provide the name of your reference person.

Acupunture history

Answer this question whether you have been treated by acupuncture in the past or not.

Main problem(s)

Provide a definition of your main health problem(s) you would like to get help for.

Problem or disease

Provide your health problem or disease.

Beginning of disease or problem

Provide information on how long ago this problem began.

Extent of the problem

Provide the extent of interference this problem causes to your daily activities. For example, the problem affects your work, sleep, etc.

Duration of the problem

Provide specific information on how long you have been experiencing this problem.

Diagnosis

Answer this question whether you have been given a diagnosis for this problem or not.

Treatment

Provide the type of treatment you have tried to resolve this problem.

Past Medical History

Provide information about your past medical history and include the dates.

Significant Illnessess

Fill out this line if you have significant illnesses such as cancer, diabetes, hepatitis, high blood pressure, heart disease, rheumatic fever, thyroid disease, seizures, or venereal disease.

Surgeries

Fill out this line if you have had surgeries before. Provide a brief description.

Significant trauma

Fill out this line if you have significant trauma caused by a vehicular accident, falls, etc.

Birth history

Fill out this line if you have birth history such as prolonged labors, forceps delivery, etc.

Allergies

Fill out this line if you have allergies.

Page 2

Family Medical History

Choose the disease that your family has a history with. You may choose from the following options:

  • Diabetes
  • Cancer
  • Stroke
  • High Blood Pressure
  • Seizures
  • Asthma
  • Allergies
  • Heart disease

Occupation

Occupational Stress

Provide a brief description if you experience occupational stress.

Regular Exercise Program

If you have a regular exercise program, briefly describe your program.

Medicines taken within the last two months

Provide the medicines you have taken within the last two months. Include vitamins, over-the-counter drugs, herbs, supplements, etc.

Restricted diet

Answer this question if you are or have ever been on a restricted diet.

Kind of diet

If you are or have ever been on a restricted diet, provide the kind of diet.

Average daily diet

Provide a description of your average daily diet during morning, afternoon, and evening.

Cigarettes

If you smoke cigarettes, enter the amount of packs you smoke per day.

Coffee, Tea, Cola

If you drink coffee, tea, or cola, enter the amount you drink per week.

Alcohol

If you drink alcohol, enter the amount you drink per week.

Drugs for non-medical purposes

Provide a description of the drugs you take for non-medical purposes, if you take any.

Page 3

General

Choose from the following options if you experience them.

  • Poor appetite
  • Fever
  • Sweat easily
  • Localized weakness
  • Bleed or bruise easily
  • Peculiar tastes or smell
  • Sudden energy drop, if you choose this option, provide the time of day when you experience this.
  • Poor sleeping
  • Chills
  • Tremors
  • Poor balance
  • Weight loss
  • Strong thirst for hot or cold drinks
  • Fatigue
  • Night sweats
  • Cravings
  • Change in appetite
  • Weight gain

Skin and Hair

Choose from the following options if you experience them.

  • Rashes
  • Itching
  • Dandruff
  • Change in hair or skin texture
  • Ulcerations
  • Eczema
  • Loss of hair
  • Hives
  • Pimples
  • Recent moles

If you have any other hair or skin problems, describe them.

Head, Eyes, Ears, Nose and Throat

Choose from the following options if you experience them.

  • Dizziness
  • Glasses
  • Poor Vision
  • Cataracts
  • Ringing in ears
  • Sinus problems
  • Grinding teeth
  • Teeth problems
  • Headaches, describe where and when
  • Concussions
  • Eye strain
  • Night blindness
  • Blurry vision
  • Poor hearing
  • Nose bleeds
  • Facial pain
  • Jaw clicks
  • Migraines
  • Eye pain
  • Color blindness
  • Earaches
  • Spots in front of eyes
  • Recurrent sore throats
  • Sores

If you have any other head or neck problems, describe them.

Cardiovascular

Choose from the following options if you experience them.

  • High blood pressure
  • Irregular heartbeat
  • Cold hands or feet
  • Blood clots
  • Low blood pressure
  • Dizziness
  • Swelling of the hands
  • Phlebitis
  • Chest pain
  • Fainting
  • Swelling of the feet
  • Difficulty in breathing

If you have any other heart or blood vessel problems, describe them.

Respiratory

Choose from the following options if you experience them.

  • Cough
  • Bronchitis
  • Difficulty in breathing when lying down
  • Production of phlegm, describe the color
  • Coughing blood
  • Pneumonia
  • Chest pain
  • Pain with a deep breath

If you have any other respiratory problems, describe them.

Page 4

Gastrointestinal

Choose from the following options if you experience them.

  • Nausea
  • Constipation
  • Black stools
  • Bad breath
  • Abdominal pain or cramps
  • Chronic laxative use
  • Vomiting
  • Gas
  • Blood in stools
  • Rectal pain
  • Diarrhea
  • Belching
  • Indigestion
  • Hemorrhoids

If you have any other problems with your stomach or intestines, describe them.

Genito-urinary

Choose from the following options if you experience them.

  • Pain on urination
  • Urgency to urinate
  • Decrease in flow
  • Frequent urination
  • Unable to hold urine
  • Impotence
  • Blood in urine
  • Kidney stones
  • Sores on genitals

Do you wake up to urinate?

Answer YES if you wake up to urinate.

Describe how often you wake up to urinate.

Urine color

If your urine has a particular color, describe it.

If you have any other problems with your genital or urinary system, describe them.

Pregnancy and Gynecology

Choose from the following options if you experience them. This section only applies to women.

  • If you have been pregnant, provide the number of pregnancies
  • If you have experienced miscarriages, provide how many
  • Provide the period between your menses
  • If you have given birth, provide how many times
  • If you have aborted, provide how many times
  • Provide the duration of your menses
  • If you have given birth prematurely, provide how many times
  • Provide your age when you first had menses
  • Provide the date of your first menses if you remember it
  • Unusual character (heavy or light)
  • Painful periods
  • Vaginal discharge
  • Changes in body or psyche prior to menstruation
  • Clots
  • Vaginal sores
  • Last PAP
  • Breast lumps

Birth control

Answer YES if you practice birth control.

Type and duration

Enter the type of birth control and how long have you been practicing it.

Musculoskeletal

Choose from the following options if you experience them.

  • Neck pain
  • Back pain
  • Hand or wrist pains
  • Muscle pains
  • Muscle weakness
  • Shoulder pain
  • Knee pain
  • Foot or ankle pains
  • Hip pain

If you have any other joint or bone problems, describe them.

Neuropsychological

Choose from the following options if you experience them.

  • Seizures
  • Areas of numbness
  • Concussion
  • Bad temper
  • Dizziness
  • Lack of coordination
  • Depression
  • Easily susceptible to stress
  • Loss of balance
  • Poor memory
  • Anxiety

Treatment for emotional problems

Answer YES if you have been treated for emotional problems.

Suicide attempt

Answer this question if you have considered or attempted suicide before or not.

If you have any other neurological or psychological problems, describe them.

Comments

Fill out this field if you have any other concerns or problems that you want to address.

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