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Medical History Form

Last, First, Middle Primary Physician

Male Female Statement of Present Health:

Today's Date D.O.B. & Age
Excellent Good

Employer Job Title Fair Poor

Medications: All prescription, non-prescription, vitamins, home remedies, or herbal medication

Name Dose (ex: mg/pill) How often? Date medication started

Medication Allergies

Social History
YES NO
Marital Status: single married divorced widowed other
Spouse / Partner Name:

Who lives at home with you?

Do you have an end of life directive? (Living will, medical power of attorney, etc.)
Tobacco Use: (type & amount per day) Date quit
Alcohol Use: (type &frequency)
Is alcohol a concern for you or others?
Caffeine Intake: None: Coffee/Tea Cups/Day Soda Cups/Day
Diet: (please rate) Good: Fair: Poor:

Seat Belt Use: always ___ occasionally ___ never ___

Are you, a relative, close friend, or companion who will be involved in your visit deaf or hard of hearing?

Current Family Health Status

Health Status (good,

Member Current Disease(s) fair or poor) Date of Birth Deceased Cause of Death
Father

Mother

Brother(s)

Sister(s)

Children

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 Patient Name:
Family Medical History
Please indicate (X) all family members* medical history (*Mother / Father, Brother / Sister, Grandmother / Grandfather) :
Relationship Relationship Relationship
Heart Disease Heart Disease Blood Disorder
High Blood Pressure High Blood Pressure Stomach Disease
Diabetes Diabetes Obesity
High Cholesterol High Cholesterol Drug/Alcohol Abuse
Stroke Stroke Mental Illness
Cancer (Incl. type) Cancer (Incl. type) Other

PAST Personal Medical History

Immunizations and date completed:
Hepatitis A Tetanus Pneumonia Rubella Polio
Hepatitis B Flu Shot Measles Varicella (chicken pox) Zostervax
Travel Vaccinations:
** Please indicate (X) and provide details for any PASTMedical History (i.e. diagnosis, dates).
Surgery or Procedure

Other Hospitalizations

Transfusion

Heart problems

Blood Pressure problems

Diabetes: Type I Type II

Elevated Cholesterol/Lipids Date of last Cholesterol test & results

Stroke

Cancer

EENT problems (eye, ear, nose and throat):

Lung problems
Gastrointestinal problems Last colonoscopy date & results
Kidney or Bladder problems
Neurologic problems
Skin problems
Bone / Muscle / Joint problems
Thyroid or other Endocrine problems

Blood Disorders
Depression / Suicide attempt or other psychiatric problems

FEMALE: Gynecological problems

Date of last Mammogram & results Ever abnormal? Y N
Abnormal breast symptoms? (describe on next page) Y N Breast Implants? Y N
Date of last Pap Smear & results Ever abnormal? Y N
MALE: Prostate problems / sexual dysfunction Date of last PSA & results
Other medical problems not previously mentioned

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 Patient Name:

CURRENT Patient Symptoms

Please indicate (X) CURRENT SYMPTOMS(please PROVIDE DETAILS for all "YES" answers in space provided):
HEAD / NECK Headache Migraine Describe:
Concussion Head Injury Describe:
Seizures Dizzy spells Details:
Fainting Light Headedness Details:
Loss of Memory Details:
Visual problems: Glasses Contacts Details:
Blind in either eye: Right Left Etiology / cause:
Color blind Double Vision Details:
Hearing Difficulties: Loss Ringing / tinnitus Details:
Hearing Aid: Right Left Details:
Environmental allergies Skin Allergies Describe:
Sinus congestion Allergy related symptoms Describe:
Mouth: Poor Teeth Toothaches Describe:
Bleeding Gums Mouth Sores Describe:
Oral Hot / Cold Intolerance Etiology / cause:
CHEST Chest Pain / Discomfort Palpitations Describe:
Shortness of Breath - At rest With exercise Describe:
Cough Cough up blood Details:
Wheeze Associated with activity What activity?
Breast lump or pain Nipple discharge Details:
THROAT Swollen Glands Difficulty Swallowing Details:
GASTROINTESTINAL Nausea Vomiting Etiology:
Diarrhea Constipation Frequency:
Change in Bowel Habits Longer than 1 week Details:
Abdominal Pain Hernia Describe:
Hemorrhoids - Internal Hemorrhoids - External Details:
Bloody or tarry stools Frequency: Associated with hard stools?
URINARY Burning with urination Frequency of urination Frequency:
Urinary Incontinence Difficulty starting stream Frequency:
Increased urination at night Inability to empty bladder Frequency:
MUSCULOSKELETAL Muscle / joint pain Muscle / joint stiffness Location:
Fracture or broken bone Limitation in motion Location:
Numbness or Tingling Weakness Location:
SKIN Rash Mole / Skin Lesion Location:
Bruise / Bleed easily Unexplained Lumps Location:
OTHER Unexplained weight loss Unexplained weight gain Number of pounds:
Excessive thirst Night sweats Frequency:
Change in energy level Weakness Details:
Fever / chills Mood swings Describe:
Anxiety Depression Describe:
Insomnia - can't fall asleep Inability to stay asleep Treatment:
Snoring Does snoring wake you? Frequency:
Daytime sleepiness Are you told you stop breathing for periods of time when asleep?
Are you sexually active? Y N Method of Birth Control:
Sexual Concerns:
FEMALES: Date of last menstrual period:

Unusual vaginal bleeding Y N Are you pregnant? Y N

MALES: Prostate Problems Y N
Please provide any other information you feel your physician should be aware of:

This information is accurate and complete to the best of my knowledge.

Patient Signature: Date:

Reviewer Name and Signature: ______________________________________________________________________________

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 Exercise Program Assessment

Staff Use
Patient Name:
Body Fat% Ht
Date:
Abd Girth Wt
CARDIO
(check all that apply) Time (min) Frequency (per wk) Intensity
Jog Low Med High
Walk Low Med High
Run Low Med High
Bike (Stationary) Low Med High
Bike (Outside) Low Med High
Elliptical Low Med High
Stair Low Med High
Swim Low Med High
Cross Country Ski Low Med High
Aerobic Class Low Med High
Row Low Med High

Low Med High

Other

STRENGTH Resistance / weight # reps / set # sets Frequency (per week)

Chest

Upper Back
Lower Back

Shoulders (Deltoids)

Triceps

Eliceps

Forearms

Mid-Section

Hips

Quadriceps

Hamstrings

Calves

Frequency # stretches/
STRETCHING/ Time held per stretch set
FLEXIBILITY (per week)
Chest

Upper Back
Lower Back

Shoulders (Deltoids)

Triceps

Biceps
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 Exercise Program Assessment

Patient Name:

Date:

Gym Member? Gym equipment @ home/work

Do you currently work with a personal trainer? Yes No If yes, frequency:

Injuries/Restrictions

FITNESS GOALS
Increase strength/endurance

Stress management

Disease Management Type

Race Event Type

Other Type

Barriers to exercise:

Additional information you wish to share:

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