"Patient Intake: Medical History Form"

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Name/Practice Name: ____________________________
Address: _____________________________________________
Address: _____________________________________________
City, State, ZIP: ________________________________________
Phone: _______________________________________________
Fax: _________________________________________________
PATIENT INTAKE: MEDICAL HISTORY
(To be completed by patient)
Use the opposite side of the page as necessary to complete your answers. Please print legibly.
Name: _____________________________________________________________________________________
Address: ____________________________________________________________________________________
Phone: (w) __________________________ (h) _________________________ (c) ________________________
DOB: _________________________ Age: ______________SS no.: ___________________________________
Emergency contact: ___________________________________________________________________________
Relationship to patient: ________________________________ Phone: _________________________________
Primary care physician: ________________________________ Phone: _________________________________
Date of last physical: _______________ Have you ever had an EKG? ( ) N ( ) Y Date: _________________
:
Current or past medical conditions (check all that apply)
( ) Asthma/respiratory
( ) Cardiovascular (heart attack, high cholesterol, angina)
( ) Hypertension
( ) Epilepsy or seizure disorder
( ) GI disease
( ) Head trauma
( ) HIV/AIDS
( ) Diabetes
( ) Liver problems
( ) Pancreatic problems
( ) Thyroid disease
( ) STDs
( ) Abnormal Pap smear
( ) Nutritional deficiency
:
Other (Please describe)
___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If there a family history of any of the illnesses listed above, please put an “F” next to that illness.
MD NOTES: __________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Name/Practice Name: ____________________________
Address: _____________________________________________
Address: _____________________________________________
City, State, ZIP: ________________________________________
Phone: _______________________________________________
Fax: _________________________________________________
PATIENT INTAKE: MEDICAL HISTORY
(To be completed by patient)
Use the opposite side of the page as necessary to complete your answers. Please print legibly.
Name: _____________________________________________________________________________________
Address: ____________________________________________________________________________________
Phone: (w) __________________________ (h) _________________________ (c) ________________________
DOB: _________________________ Age: ______________SS no.: ___________________________________
Emergency contact: ___________________________________________________________________________
Relationship to patient: ________________________________ Phone: _________________________________
Primary care physician: ________________________________ Phone: _________________________________
Date of last physical: _______________ Have you ever had an EKG? ( ) N ( ) Y Date: _________________
:
Current or past medical conditions (check all that apply)
( ) Asthma/respiratory
( ) Cardiovascular (heart attack, high cholesterol, angina)
( ) Hypertension
( ) Epilepsy or seizure disorder
( ) GI disease
( ) Head trauma
( ) HIV/AIDS
( ) Diabetes
( ) Liver problems
( ) Pancreatic problems
( ) Thyroid disease
( ) STDs
( ) Abnormal Pap smear
( ) Nutritional deficiency
:
Other (Please describe)
___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If there a family history of any of the illnesses listed above, please put an “F” next to that illness.
MD NOTES: __________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Page 1 of 4
Is there a family history of anything NOT listed here? ( ) N ( ) Y (Please explain) _______________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MD NOTES: _______________________________________________________________________________
___________________________________________________________________________________________
Have you ever had surgery or been hospitalized? ( ) N ( ) Y (Please describe) _________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MD NOTES: _______________________________________________________________________________
___________________________________________________________________________________________
Childhood Illnesses
Measles
( ) N
( ) Y
Mumps
( ) N
( ) Y
Chicken Pox
( ) N
( ) Y
Have you or a family member ever been diagnosed with a psychiatric or mental illness? ( ) N ( ) Y (Please
describe) ___________________________________________________________________________________
Have you ever taken or been prescribed antidepressants? ( ) N ( ) Y For what reason ___________________
Medication(s) and dates of use: ______________________________ Why stopped: _______________________
Please list all current prescription medications and how often you take them (example: Dilantin 3x/day).
DO NOT include medications you may be currently misusing (that information is needed later): ______________
___________________________________________________________________________________________
___________________________________________________________________________________________
Please list all current herbal medicines, vitamin supplements, etc, and how often you take them: ____________
___________________________________________________________________________________________
MD NOTES: _______________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Please list any allergies you have (eg, penicillin, bees, or peanuts): _____________________________________
___________________________________________________________________________________________
MD NOTES: _________________________________________________________________________ ______
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Tobacco History
Cigarettes: Now?
( ) N
( ) Y
In the past?
( ) N
( ) Y
How many per day, on average? _________
For how many years? _________
Pipe: Now?
( ) N
( ) Y
In the past?
( ) N
( ) Y
How often per day, on average? _________
For how many years? _________
Have you ever been treated for substance misuse? ( ) N ( ) Y (Please describe when, where and for how
long)
____________________________________________________________________________________________________
How long have you been misusing substances?
___________________
Substance Use History
Yes/Past
Date/Time
Quantity
No
or
Route
How Much
How Often
of Last Use
Last Used
Yes/Now
Alcohol
Caffeine (pills or
beverages)
Cocaine
Crystal Meth-
Amphetamine
Heroin
Inhalants
LSD or
Hallucinogens
Marijuana
Methadone
Pain Killers
PCP
Stimulants (pills)
Tranquilizers/
Sleeping Pills
Ecstasy
Other
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Did you ever stop using any of the above because of dependence? ( ) N ( ) Y (Please list) ________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What was your longest period of abstinence? ______________________________________________________
___________________________________________________________________________________________
Are you receiving, or have you ever received counseling support? ( ) N ( ) Y (Please describe when and for
how long) _________________________________________________________________________________
___________________________________________________________________________________________
MD NOTES: _______________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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