Microsoft word - health history rev 05012013.docx

Patient Name______________________________________________ Today’s Date____________________ Age:________________ Mail Order Pharmacy Name/Address:
__________________________________________________________
Phone:____________________________________
Local Pharmacy Name/Address:
______________________________________________________________
Phone: ___________________________________

Allergies? (Circle) Yes (if yes, please list below) or No
______________________________________________________________________________________
______________________________________________________________________________________

Medication List

Please list all medications: Prescription/over the counter/vitamins/supplements
List dosage and how often you take Example: Flomax 0.4 mg 1 tablet a day
Name

1.________________________________ __________ ________________________________
2.________________________________ __________ ________________________________
3.________________________________ __________ ________________________________
4.________________________________ __________ ________________________________
5.________________________________ __________ ________________________________
6.________________________________ __________ ________________________________
7.________________________________ __________ ________________________________
8.________________________________ __________ ________________________________
9.________________________________ __________ ________________________________
10.________________________________ __________ ________________________________
Surgical History

List all Surgery from childhood to present including year of surgery. Example: Tonsils removed 1989
1.______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________
4.______________________________________________________________________________________
5.______________________________________________________________________________________
6.______________________________________________________________________________________
7.______________________________________________________________________________________
Patient Name______________________________________________ Today’s Date____________________ SYMPTOMS: Check (√) symptoms you currently have or have had in the past year.
CONSTITUTIONAL
EARS, NOSE, MOUTH,
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
INTEGUMENTARY/
NEUROLOGICAL
HEMATOLOGIC/
LYMPHATIC
□ Persistent Itching
CONDITIONS: Check (√) conditions you have or have had in the past.
□ AIDS
□ Constipation

Source: http://www.southwesturology.com/patientforms/healthhistory_2014.pdf