Patient Medical History Form

Please Note: All information is confidential and will become part of your medical record

Please do not leave any boxes empty, mark N/A for not applicable or unknown if appropriate.

Patient's Name:

Date of Birth:

Today’s Date:

Age:

Gender:

Guardian 1 Name:

DOB:

Relationship to Patient:

Guardian 2 Name:

DOB:

Relationship to Patient:

Patient Lives With:

Both Parents

One Parent

Other

Please explain:

Family status:

Married

Divorced

Partner

Single

How did you hear about us?

Ethnicity:

Decline to answer

Hispanic or Latino

Not Hispanic or Latino

Race:

Decline to answer

Black or African American

American-Indian or Alaska Native

Asian

Native Hawaiian or Pacific Islander

White

Other:

Preferred Language:

Decline to answer

Birth History

Is the patient adopted:

Yes

(If “yes” please answer to the best of your knowledge.)

Place of birth:

Birth Weight:

Birth Length:

Discharge Weight:

Complications with pregnancy:

Yes

If yes, please explain

Did the patient receive the Hepatitis B vaccine at birth?:

Yes

If Yes, Date

Obstetrician:

Vaginal Delivery

Cesarean Section

Complications with delivery:

Yes

If yes, please explain

Full Term((greater than 38 weeks gestation)):

Yes

If not full-term, gestational age at birth (weeks):

Jaundice:

Yes

Unknown

Breech Presentation:

Yes

Unknown

APGAR Scores:

1 minute:

5 Minute:

Unknown

Social History

Does the patient live with anyone who smokes?

Yes

Does the patient have siblings?

Yes

If Yes, How many?

Please provide details of others living in the household:

Name:

Age:

Relationship to Patient:

Name:

Age:

Relationship to Patient:

Name:

Age:

Relationship to Patient:

Name:

Age:

Relationship to Patient:

Name:

Age:

Relationship to Patient:

Name:

Age:

Relationship to Patient:

Name:

Age:

Relationship to Patient:

Name:

Age:

Relationship to Patient:

Name:

Age:

Relationship to Patient:

Name:

Age:

Relationship to Patient:

Patient's Name:

Date of Birth:

Today’s Date:

Medical History

Patients’ previous physician, if any:

Date of last well exam: (if known):

Was last exam normal:

Yes

If no, please explain:

Immunizations up to date:

Yes

Unknown

If no – please explain:

Does the patient have any current or past medical problems?

Yes (please describe below)

Unknown

Current or Past Medical Problems:

Dates:

Reasons:

Current or Past Medical Problems:

Dates:

Reasons:

Current or Past Medical Problems:

Dates:

Reasons:

Does the patient have any past hospitalizations or surgeries?

Yes (please describe below)

Unknown

Hospitalizations/Surgical History:

Date:

Reason:

Hospitalizations/Surgical History:

Date:

Reason:

Hospitalizations/Surgical History:

Date:

Reason:

Is the patient currently on any medications? Either prescription or over-the-counter

Yes (please describe below)

Unknown

Medications/Supplements:

Dosage/Frequency:

Condition/Reason:

Medications/Supplements:

Dosage/Frequency:

Condition/Reason:

Medications/Supplements:

Dosage/Frequency:

Condition/Reason:

Does the patient have any allergies?

Yes (please describe below)

Unknown

Allergies (Medication, Food, Cosmetics, Etc.):

Cause/Nature of Reaction:

Allergies (Medication, Food, Cosmetics, Etc.):

Cause/Nature of Reaction:

Allergies (Medication, Food, Cosmetics, Etc.):

Cause/Nature of Reaction:

Allergies (Medication, Food, Cosmetics, Etc.):

Cause/Nature of Reaction:

Have you EVER had any of the following?

Thyroid disorder:

Yes

Asthma/Breathing problems:

Yes

Behavioral problems:

Yes

Stomach problems:

Yes

Developmental Disorder:

Yes

Diabetes:

Yes

Liver disease:

Yes

Ongoing issues with Ear/nose/throat:

Yes

Skin disorder/Eczema:

Yes

Eye disorder:

Yes

Growth disorder:

Yes

Heart disorder/defect:

Yes

Kidney/bladder problems:

Yes

Seizures or Epilepsy:

Yes

Family History

Has anyone in the patient’s family had any of the following?

Heart disease or stroke

Parent

Sibling

Other Relative

Hypertension

Parent

Sibling

Other Relative

Diabetes

Parent

Sibling

Other Relative

High cholesterol

Parent

Sibling

Other Relative

Gastrointestinal problems

Parent

Sibling

Other Relative

Describe:

Cancer

Parent

Sibling

Other Relative

Type:

Respiratory problems

Parent

Sibling

Other Relative

Describe:

Neurological problems

Parent

Sibling

Other Relative

Describe:

Vision problems

Parent

Sibling

Other Relative

Describe:

Development delays

Parent

Sibling

Other Relative

Describe:

Anemia

Parent

Sibling

Other Relative

Describe:

Depression/Anxiety

Parent

Sibling

Other Relative

Describe:

EMERGENCY CONTACT

In case of an emergency who should we contact?

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Signature

Printed Name:

Date