Medical History Form
1. Name: _________________________________ Date of Birth: _____________ Date:_______
2. Current Medical Providers: (Please list names, specialty, and phone numbers)
a. ______________________________________________________ b. ______________________________________________________ c. ______________________________________________________
a. Medication: _______________ - Reaction: ______________________ b. Medication: _______________ - Reaction: ______________________ c. Medication: _______________ - Reaction: ______________________
4. Current Medications (please include over the counter and herbal medications. Use a separate piece of
5. Medical History: (Please list chronic diseases, surgeries, hospitalizations, and major illnesses to the best
of your memory. Details will be discussed with the doctor. Use separate piece of paper if needed)
Event: Month/Year Hospital or Treating Physician
Medical History Page 2
Family Member: Medical Condition Age at Diagnosis Age at Death(if applicable)
a. Tobacco Use: __No __Yes- Type:__________ Yrs:_____ Quit?____ When:_____ b. Alcohol Use: __No __Yes- How Many Drinks per Day:___ Per Week: ___
i. Problems related to alcohol use? ___No ___Yes
c. Other Drug Use: __No __Yes- (discuss details with Physician) d. Caffeine: __No __Yes- Number of Cups per Day: ______ e. Stress Level: ____ Low _____Average ____ High f. Work History:
Work Number of Years Related Health Concerns?
i. Married? __Yes __No- ___Widowed ___Divorced __Significant Other
ii. Children? __No __Yes- Ages?___________________
1. Good relationship with your children? __Yes __No
iii. Are you satisfied with your sexual health? __Yes __ No
i. During the past month have you often been bothered by feeling down, depressed, or
ii. During the past month have you often been bothered by little interest or pleasure in doing
i. Regular Exercise: __No __Yes- Type:____________ Frequency:___________
8. Preventative Health History (Indicate year received if possible, leave blank if not applicable)
a. Last Tetanus/Pertussis Vaccine: ______ (Recommended every 10yrs) b. Pneumonia Vaccine: _______ (Once after age 65yrs or every 5yrs with lung disease) c. Shingles Vaccine (Zostavax): _______ (Once after age 65yrs) d. Last Flu Vaccine: ______ (Recommended every year in Oct/Nov) e. Cervical Cancer Vaccine (Gardisil): _______(3 dose vaccine Recommended for young women) f. Other Vaccines: _________________________________________________________
g. Mammogram: ___________ (Recommended for Women >40yrs every 1-2yrs) h. Pap Smear: ____________ (Recommended for sexually active women till 65yrs with a cervix) i. Bone Density: _____________(Recommended for women >65yrs or >60yrs with high risk)
j. Prostate Exam & PSA:_________ (controversial but generally recommended yearly >50yrs) k. Aortic Aneurysm Screen: __________ (Recommended for Men >65yrs who have ever smoked)
l. Colonoscopy: ___________ (Recommended after age 50yrs or 10 yrs younger than relative
m. Any other Screening exams or testing that may be of interest?
9. Any other information that the doctor should know or that you are concerned about?
Thank you for taking the time to complete this form. We will use this information to optimize your
visits and the care you receive. Regards, Little Black Bag Medical
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