Wilson Medical Group Medical History Form

Wilson Medical Group

HISTORY FORM

Patient Name: ______Date: ______

Please check all that you have a history of:

0 Allergy0 Eye Disease 0 Hepatitis0 Thyroid Disorder

0 Asthma 0 Hearing Disorder0 Incontinence -hypo/hyper

0 COPD 0 Cancer0 GERD (reflux)0 Depression

0 Pneumonia - Type______0 Irritable Bowel Syn 0 Anxiety

0 High Blood Pressure 0 Seizures0 Diabetes0 Mental Illness:

0 High Cholesterol 0 Migraines0 Eczema/psoriasis -type______

0 Heart Attack 0 Stroke0 HIV0 Fibromyalgia

0 Heart Murmur 0 Neck/Back Pain0 Anemia0 Other

0 Artificial Heart Valve 0 Osteoporosis0 Bleeding Disorder ______

0 Atrial Fibrillation 0 Kidney Disease0 Blood Clot ______

Please list all Surgeriesand Date of surgery: Please list all doctors you currently see:

______1______

______2______

______3______

______4______

FAMILY HISTORY

Father: Date of Birth______Living Yes or No If deceased, age at death: ______

List any medical conditions: ______

______

Mother: Date of Birth______Living Yes or No If deceased, age at death: _____

List any medical conditions: ______

______

Brothers: Number Living ______Number Deceased ______If deceased age at death: ______

List any medical conditions: ______

Sisters: Number Living ______Number Deceased ______If deceased age at death: ______

List any medical conditions: ______

Sons: Number Living ______Number Deceased ______If deceased age at death: ______

List any medical conditions: ______

Daughters: Number Living ______Number Deceased ______If deceased age at death: _____

List any medical conditions: ______

**PLEASE SEE OTHER SIDE**

SOCIAL HISTORY

Marital Status: (circle one) Single Married Widowed Divorced

Do you use alcohol: Yes or No If yes, how many drinks per week? ______

Do you smoke? Yes or No -If yes, how much per day?______Age started____ Age quit____

Employment Status (circle one) working retired unemployed disabled

Occupation ______

IMMUNIZATIONS/VACCINATION/SCREENING TESTS

(Please list date of your last)

Tetanus shot ______Colonoscopy ______

Pneumonia vaccine ______PSA/prostate exam ______

Shingles vaccine ______Eye exam ______

Gardasil/HPV vaccine ______Cholesterol check ______

Hepatitis B vaccine ______Stress test ______

Flu shot ______Bone density ______

Whooping cough vaccine ______Diabetic foot exam ______

PPD ______Sleep study ______

REVIEW OF SYMPTOMS

(Please circle any of the following that you are concerned about)

weight loss/gaincoughjoint pain

feverswheezingmuscle spasm/pain

headachesshortness of breathneck/back pain

rashnauseaheat/cold intolerance

itchingdiarrheaseizures

hivesabdominal painnumbness

congestionurinary frequencydizziness

ear painincontinencedepression

sore throatburning with urinationanxiety

chest painvaginal dischargetrouble sleeping

leg swellingirregular periods

palpitationserectile dysfunction

ADVANCE DIRECTIVES

Do you have a Living will? (circle one) Yes or No

Do you have Power of Attorney for health care (circle one) Yes or No

- If Yes: (Name/Phone#) ______