Medical History Form: Example

It wasn't until I gave my doctor a chart simular to this one that he gave me the diagnosis of fibromyalgia.  I was not a "complainer" and it was difficult for me to speak the litany of "minor aches and pains" I dealt with.  Filling this out completely and adding a second page with comments about your general health can make it easier for both you and your doctor to assess your health complaints both specifically and in general.  I keep a copy of this page in my wallet.  When seeing a new doctor in the seemingly endless parade of medical practicioners in my life, it helps me to complete their forms even when the fibrofog is thick.  In fact, while I was making out my own medical history form the fog was too thick to remember it all in one day.  I found myself coming back to it as something would jog my memory.  Below the example, I've posted a list of maladies that may help jog yours. 

One of the things my doctor seems to like is a written list of present complaints each time I see him.  He will take my list and write his answers for me.  I type those lists now and leave him plenty of room for complete answers.  I've posted a list to jog your memory when you're making up your next list for a doctor appointment.

PHYSICIANS

DIAGNOSES

MEDICATION ALLERGIES

MEDICATION SENSITIVITIES

SURGERIES

Family Practice:

Dr. Smith
Rodeo Drive
Hollywood, CA
(232) 555-1783

Fibromyalgia

Penicillin:  Makes my throat swell shut

Valium:  Opposite affect.  Makes me anxious

1982: Cholecystectomy
St. Francis Hospital
Chicago, IL
Dr. Smith

Morphine:  Makes me swell up all over

Counselor

Ehlers-Danlos Syndrome

Aspirin:  Causes Asthma reaction

 

 

Neurologist

Thyroid disease

 

 

 

Orthopedist

 

 

 

 

Gastroenterologist

 

 

 

 

Geneticist

 

 

 

 

 

 

 

 

 

CURRENT MEDICATIONS

FOOD ALLERGIES:

PAST HISTORY

VACCINATIONS:

 

Synthroid:  .02 mgs daily

Milk:  Asthma reaction

Mono:  1972

Up to Date

 

Vicodin:  ( ) mgms, every 4-6 hours prn

Wheat:  Hives

Scarlet fever:  1964

 

 

 

 

Pneumonia:  193

 

 

 

 

Strep throat:  twice a year for all of my childhood

 

 

TOBACCO Cigarrettes
2 pcks day

ALCOHOL Communion
1/2 glass of wine with dinner every few days      

WEIGHT

152 lbs

HEIGHT

5'2"

 

Updated:  January 1, 2005

MEDICAL HISTORY FORM MEMORY JOGS

Rate your healthExcellent, Good, Fair, Poor
MEDICATIONS:Prescription and non-prescription medicines,
vitamins,
home remedies,
birth control pills,
herbs

When were your most recentIMMUNIZATIONS:
Hepatitis A ____
Hepatitis B ____
Influenza (Flu Shot) ____
Measles ____
Pneumovax (Pneumonia) ____
Rubella ______
Tetanus (Td) ___
Varicella (chicken pox) shot_____
orIllness ____
When were your most recentHEALTH MAINTENANCEscreening tests:
Lipid (Cholesterol Screening) ____ Results? ___________
Mammogram____ Results? ________________________Ever abnormal?
Pap Smear ____ Results?___________________________Ever abnormal?
(Prostate cancer screen) ____ Results? _______
Stool test for blood ____ Results? _______________
Sigmoidoscopy? _____ Results? ________________

PERSONAL MEDICAL HISTORY:
Heart disease:specify type
Heart attack
High blood pressure
Diabetes
High cholesterol
Thyroid problem specify type
Bleeding/clotting problem
Blood transfusion
Cancer (Malignancy)specify type
Stroke
Depression/suicide attempt
Alcoholism


FAMILY HISTORY:Please indicate the current status of your immediate family members:Alive, Deceased, Age (now or at death)Comments/Cause of death
Mother:
Father:
Sister(s)
Brother(s)
Daughter(s)
Sons(s)
Alcoholism
Anemia
Anesthesia problem
Arthritis
Asthma
Autoimmune disorder
Bleeding problem
Cancer,
Breast Cancer,
Colon Cancer,
Melanoma
Cancer,
Ovary Cancer,
Prostate
Heart Attack (Coronary Artery Disease)
Birth Defects
Depression
Diabetes, Type 1 (childhood onset)
Diabetes, Type 2 (adult onset)
Eczema
Food allergies
Genetic diseases
Hay fever
Hearing problems
High cholesterol (Hyperlipidemia)
High Blood Pressure (Hypertension)
Immunosuppressive disorders
Kidney diseases
Mental retardation
Osteoporosis
Epilepsy (seizure disorder)
Stroke
Substance abuse
Thyroid disorders
Smoking
Tuberculosis
YesDrug UseDo you use any recreational drugs?
Have you ever used needles?
Have you ever had any sexually transmitted diseases(STDs)?
Do you take SUPPLEMENTS? __________
For women: # pregnancies: ____ # deliveries: ____ # abortions: ____ # miscarriages: ____1st day, most recent period: _______ Age at 1st period: ______ Frequency of periods: _______ Length of each: ______Do you have any concerns about your periods? ❑ No ❑ Yes:________________________________________________Do you have any concerns about menopause? ❑ No ❑ Yes:________________________________________________
 

 

 

Arthritis
Heart Disease
Seizures/Convulsions
Asthma
High Blood Pressure
Tuberculosis
Diabetes
Kidney Disease
Ulcer: Duodenal/Peptic
German Measles
Malignant
Measles
Arthritis (describe)
Rheumatic Fever
Asthma (describe)
Scarlet Fever
Digestive Problem (describe)
Jaundice
Chest Pain/Pressure
Head Injury (describe)
Malaria
Dizziness/Fainting
High Blood Pressure
Mononucleosis
Recent Gain/Loss of Weight
Heart Disease/Problem
Recurrent Colds/Sinusitis
Weakness/Paralysis
Kidney Disease (describe)
Hay Fever
Sexually Transmitted Disease
Diabetes
Dental
Hernia
Seizures/Convulsions
Hives
Tuberculosis
Shortness of Breath
Hernia Repair
Anemia
Tonsillectomy
Headaches
Diarrhea
Excessive Menstrual Flow
Irregular Periods
Severe Cramps
Anxiety/Depression
Back Problems
Worry/Nervousness
Chronic Cough
Alcohol/Drug Dependency
Gallbladder problems
Has your physical activity been restricted in the past? (Give reasons and duration).
Have you ever received treatment or counseling for any eating
disorder, emotional or psychiatric problem?
Have you had: Measles, Mumps, Rubella
 

 

 

REVIEW OF PRESENT SYMPTOMS:


 Fevers/chills/sweats
Unexplained weight loss/gain
Change in energy/weakness
Excessive thirst or urinationEyes
Change in vision
Difficult hearing/ringing in ears
Problems with teeth/gums
Hay fever/allergies
Chest pain/discomfort
PalpitationsChest (breast)
Breast lump/nipple discharge
Respiratory
Cough/wheeze
Difficulty breathing
Gastrointestinal
Abdominal pain
Blood in bowel movement
Nausea/vomiting/diarrhea
Nighttime urination
Leaking urine
Unusual vaginal bleeding
Discharge: penis or vagina
Muscle/joint pain
Rash/mole change
Headaches
Dizziness/light-headedness
Numbness
Memory loss
Loss of coordination
Psychiatric
Anxiety/stress
Problems with sleep
Depression
Blood/Lymphatic
Unexplained lumps
Easy bruising/bleeding
Problems with sexual function