Personal History & Evaluation of Patient Health Form

Patient Information:
Name:
Date of Birth:
Gender: MaleFemaleOther
Contact Number:
Email:

Reason for Visit:

Past Medical History:
Select any common diseases you have had:
DiabetesHypertensionHeart DiseaseAsthmaCancerArthritisThyroid DisordersStrokeChronic Kidney DiseaseCOPDOsteoporosisAnemiaHepatitisMental Health DisordersAutoimmune DiseasesOther

Marital Status:
SingleMarriedDivorcedWidowedOther

Personal Habits:
Smoking: YesNo
Drinking: YesNo
Other Substances Used:

Past Operations:
1.
2.
3.

Serious Injuries:
1.
2.
3.

Hospitalizations:
1.
2.
3.

Urgent Care/ER Visits:
1.
2.
3.

Radiation Treatments:
1.
2.
3.

Family History:
(Fill in "Health," "Age," and check if "Deceased")
Father: Yes
Mother: Yes
Sister(s): Yes
Brother(s): Yes
Wife/Husband: Yes
Daughter(s)/Son(s): Yes

Body System Review:
Have you experienced any of the following symptoms in the last 3 months constantly, more than 2-3 times a week?
Skin: RashesItchingDrynessOther
Eyes: Blurred VisionRednessDrynessOther
Nose and Throat: CongestionSore ThroatNosebleedsOther
Breasts: LumpsPainNipple DischargeOther
Musculoskeletal: Joint PainMuscle WeaknessBack PainOther
Digestive: NauseaVomitingDiarrheaOther
Genitourinary: Frequent UrinationPainful UrinationBlood in UrineOther
Endocrine: Excessive ThirstExcessive HungerWeight FluctuationsOther
Neurologic: HeadachesDizzinessNumbnessOther
General: FatigueFeverWeight LossOther
Heart and Lung: Chest PainShortness of BreathCoughOther

Past Medications and Dosage:
1.
2.
3.

Medical Allergies:
1.
2.
3.

Other Comments: