New Patient Medical History Form

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Chief Complaint

HPI (History of the Present llness)

Full Name

Today's Date:

Address

Date of Birth:

Age

Allergies

Reactions

Previous history of illness

Which illness?

Personal Medical History

Current

Past

Comments

Previous Screening Tests Date

Previous Screening Tests Facility

Previous Screening Tests Results

Surgeries (left/right)

Surgery Date

location / facility

Womens Health History:

Date of last menstrual period

Age at first menstruation

Total number of pregnancies

Number of live births

Pregnancy complications

Family Medical History

Social History:

Do you smoke ?

Cigarettes per day?

Number of years for smoking

Quit smoking? / How long?

Do you drink alcohol ?

Drinks per day?

Number of years for drinking

Quit drinking? / How long?

Marijuana use?

Marijuana cigarettes per day?

Number of years?

Quit marijuana ? / How long?

Other drugs?

Ever used needles to inject drugs ?

Sexual Histroy:

Sexually active?

Number of partners

History of STD?

Name of STD?

Treatment?

Have you traveled outside of the country lately ?

Date of last travel?

list of current medications

Additional information that you would like to add (copy)

Upload Your Test Reports

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