Patient Medical History 

Confidential 

 

Patient Name________________________________________________ Today’s Date______________ 
 
Date of Birth________________________Age__________SSN_________________________________ 
 
Height_____________ Weight____________ Emergency Contact _______________________________ 
 
E-mail Address:________________________________________________________________________ 
 
Referring Doctor_______________________ Family Physician _________________________________ 
 
Chief Complaint ______________________________________________________________________ 

(Reason for today’s visit) 

 

Current Medications   

 

 

 

Dose 

 

   Frequency  

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
_______________________________________________________________________________________

 

_______________________________________________________________________________________ 
_______________________________________________________________________________________

 

 
Have you taken any aspirin, ibuprofen or arthritis medicine in the last two weeks?_____________________ 
If so when?________________________________ Do you bruise easily? ___________________________ 
 
DRUG ALLERGIES:
_____________________________________________________________________ 
 
Medical Illnesses: 
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________ 
_______________________________________________________________________________________ 
 
Hospitalizations
 

 

 

 

 

 

Date 

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
 
 
 
 
 
 
 

 
Surgical Procedures
 

 

 

 

 

 

Date 

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
 
Have you ever had problems with anesthesia?  __Yes    __No 
If yes, describe:__________________________________________________________________________ 

 

Release of Records 

 
Who may have access to your medical records? 
Name   

 

 

Relation 

 

 

 

Contact Information 

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 

 

Family History 

 
Family Member

 

 

Medical Illnesses

 

Mother  

 

 

_____________________________________________________________ 

Grandparents (maternal)  

_____________________________________________________________ 

Father   

 

 

_____________________________________________________________

 

Grandparents (paternal)  

_____________________________________________________________ 

Sister(s) / Brother (s) 

 

_____________________________________________________________

 

 

Social History 

 

Are you presently working or going to school full or part time? ____________________________________ 
 
Employer / School: _______________________________________________________________________ 
 
Marital Status:______________ Do you live alone? _________ Who lives with you?___________________ 
 
Do you have children?______ If yes, how many?________________________________________________ 
 
Do you smoke?  __Yes         __No       Cigars?___________ Pipe?__________ Chewing tobacco?_________ 
 
Cigarettes per day?_______________ How long have you been chewing or smoking ___________________ 
 
Do you drink alcohol?  __Yes         __ No 
Is it  

__Social 

 __Heavy 

 __Prior addiction? 

 
Do you take or have you taken recreational drugs?   __Yes   

__No         __Prior addiction 

 
Do you have any difficulty sleeping? 
__Never 

__Often 

__Sometimes       __Getting to sleep 

   __Staying awake 

 
Does anyone complain that you snore?  __Yes     __ No 
 
Do you stop breathing at night?              __Yes     __No 

 
Do you wake up tired in the morning?    __Yes     __ No 
 
Do you fall asleep in the daytime?          __Yes      __No 
 
Caffeine intake: _________________________________________________________________ per day 
 
Do you exercise?  __ Yes    __No                   Type/Frequency:___________________________________ 
 
Are you at risk for AIDS? If yes, explain ____________________________________________________ 

Review of Systems 

 

 
Are you currently having, or have you had problems with: (check all that apply) 
 

General well-being 
__ Fever 
__ Weight loss (>10#) 
__ Excess fatigue 
__ Recurrent Nausea / vomit 
__ Night sweats 
 
Eyes 
__ Wear glasses 
   Date of last exam ______ 
__ Infections 
__ Injuries 
__ Glaucoma 
__ Cataracts 
__ Blurred vision 
__ Trouble focusing 
__ Recent change in vision 
 
Ears, Nose, Mouth and 
Throat 
__ Wear hearing aids 
   Date of last exam_______ 
__ Hearing loss 
__ Ear infection 
__ Pressure in ears 
__ Ringing in ears 
__ Pain in ears 
__ Balance disturbance 
__ Itching in ears 
__ Dizziness 
__ Nasal congestion 
__ Nasal drainage 
__ Nosebleeds 
__ Sinus problems 
__ Sinus infections 
__ Sinus headaches 
__ Throat infections 
__ Difficulty swallowing 
__ Lip or mouth sores 
__ Sore throats 
 
 
 
 

Respiratory 
__ Chronic cough 
__ Emphysema 
__ Bronchitis 
__ Asthma 
__ Chronic obstruction 
__ Pulmonary disease 
__ Shortness of breath 
__ Oxygen use at home 
__ Pneumonia  
__ Lung cancer 
__ Tuberculosis 
__ Blood in saliva 
   Date of last chest                                                                            

X-ray_____ 

 
Cardiovascular 
__ Chest pain 
   Date of last EKG _______ 
__ Heart attack 
__ High blood pressure 
__ Low blood pressure 
__ Irregular heartbeat 
__ Heart murmur  
__ Arm and leg swelling 
__ High cholesterol 
 
Gastrointestinal  
__ Blood in vomit 
__ Indigestion 
__ Nausea / vomiting 
__ Jaundice 
__ Abdominal pain 
__ Change in bowel habits 
__ Ulcers or Gastritis 
__ Colon, liver, stomach 

cancer 

__ Hepatitis 
 
Hematologic 
__ Anemia 
__ Hemophilia 
__ Easy bleeding / bruising 
__ Swollen glands 

Genitourinary 
__ Urinary tract infection 
__ Painful urination 
__ Blood in urine 
__ Difficulty urinating 
__ Incontinence 
__ Kidney stones 
__ Prostate cancer 
__ Endometriosis 
__ Uterine, ovarian or 
      cervical cancer 
 
Neurological 
__ Disorientation 
__ Fainting / blacking out 
__ Light headedness 
__ Seizures 
__ Stroke 
__ Mini-stroke 
__ Memory problems 
__ Concentration problems 
__ Speech problems 
__ Facial weakness/ spasms 
__ Muscle weakness 
__ Coordination problems 
__ Uncontrolled shaking 
__ Headache 
__ Migraine 
 
Endocrine 
__ Diabetes 
__ Hormone problems 
__ Low blood sugar 
__ Thyroid disease 
__ Increased appetite 
__ Excessive thirst 
__ Excessive urination 
__ Temperature intolerance 
__ Pituitary gland problems 
__ Bleeding tendencies 
 
 
 
 

Immunologic 
__ Environmental allergies 
__ Hay fever 
__ Food allergies 
__ Immune system problems 
__ Connective tissue disease 
__ Frequent colds / infections 
 
Skin 
__ Eczema or psoriasis 
__ Dermatitis 
__ Dry or scaling skin 
__ Rashes 
__ Changes in skin color 
__ Changes in moles 
__ Skin cancer 
__ Breast pain or swelling 
     Date of last Mammogram 
      _____________ 
 
Musculoskeletal 
__ Broken bones 
   list:_______________ 
__ Arm or leg weakness 
__ Joint pain or swelling 
__ Back pain 
__ Arthritis 
 
Psychiatric 
__ Anxiety 
__ Depression 
__ Manic/Depression 
__ Schizophrenia 
__ Considering suicide /            

homicide 

__ Panic attacks 
__ Sudden mood swings 
__ Emotional difficulties 
__ Insomnia 

_    __ Other psychiatric   

problems 

__ Under psychiatric care 
__ Desiring psychiatric care 

________________________________________________________________________________________________________
The above information is accurate to the best of my knowledge
 
____________________________________________________ 

 

________________________ 

Patient Signature  

 

 

 

 

 

 

Date 

 
I have reviewed the above information with the patient.  
 
_____________________________________________________ 

 

_________________________ 

Boris Karanfilov, M.D. / Sumit Bapna, M.D.  

 

 

 

Date