Medical History Form PDF Details

When visiting a healthcare provider or undergoing a new treatment, patients are often asked to complete a Medical History Form. This essential document provides a comprehensive overview of an individual's health, capturing everything from personal to family medical history. The form typically starts with basic personal information, including date of birth, gender, weight, and height. It delves into general medical and dental histories, asking about overall health status, any changes in health over the past year, and details about any current treatments or medications. Important aspects like major hospitalizations, surgeries, allergies, and even lifestyle habits such as exercise and tobacco or alcohol use are covered to give healthcare providers a full picture of the patient's health. For women, it includes specific questions about pregnancy status or menopause. Additionally, the form asks about past and present symptoms across various systems in the body, from cardiovascular to neurological issues. Recognizing the significance of family health history, patients are also asked to disclose any genetic diseases or other conditions present within their family. This document plays a crucial role in guiding healthcare professionals to deliver personalized and effective care, highlighting the importance of accuracy and completeness when patients fill it out.

QuestionAnswer
Form NameMedical History Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesprintable medical history form template, health history form example filled out, online medical history form, medical history form template

Form Preview Example

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NAME:

 

 

 

 

 

DATE:

 

 

 

 

 

CHART:

 

 

 

 

 

 

 

UNIVERSITY OF WASHINGTON SCHOOL OF DENTISTRY - MEDICAL AND DENTAL HISTORY

GENERAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. a. Date of Birth: ____

___

____

 

b. Gender:

Male

 

 

c. Weight: ______ lbs.

 

 

 

 

Month

Day

Year

 

 

 

Female

 

d. Height: ____ ft. ____ inches

 

 

e. Highest grade of regular school that you have completed? _________

f. Employed?

Yes

No

GENERAL MEDICAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Please rate your health.

Excellent

Very Good

Good

 

Fair

 

Poor

 

 

 

 

3.

Has there been a change in your general health in the past year?

Yes

No

 

 

 

 

 

 

 

4.

Your Physician:

 

 

 

 

 

City_____________________

Phone No.: _______________________

 

 

5.

Date of last physical examination: Month _____Year ______ Currently under treatment by a physician?

Yes No

 

 

 

Please explain______________________________________________________________________________

 

 

6.

Do you engage in regular exercise?

Yes

No Type____________________________________________

 

 

7.

Do you need to take antibiotics prior to receiving dental or surgical care?

 

Yes

No

Don’t know

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAJOR HOSPITALIZATIONS, SURGERIES, AND BLOOD TRANSFUSION MARK HERE IF NONE VERIFIED BY EXAMINER

 

8.

DATE (Month/Year)

REASON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______

 

 

 

_________________________________________________________________________________________________________

 

 

_________________________________________________________________________________________________________

 

 

_________________________________________________________________________________________________________

 

 

_________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

ALLERGIC OR UNUSUAL REACTION TO ANY OF THE FOLLOWING?

MARK HERE IF NONE

VERIFIED BY

 

 

 

 

 

 

 

 

 

 

EXAMINER

 

9.

Penicillins

Opiates/codeine

Other drugs:

Other substances (food, metals, etc.)

 

 

 

 

Sulfa drugs

Iodine

List: 1. ____________________

List: 1.

___________________________

 

 

 

 

 

Aspirin

Latex

2. ____________________

2. ___________________________

 

 

 

 

 

Local anesthesia

3. ____________________

3. ___________________________

 

 

 

 

Type of Reaction ________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

WOMEN ONLY

 

 

 

 

 

NOT APPLICABLE

 

10.

Are you

PREGNANT? ____ weeks?

Trying to become pregnant?

Not sure if you are pregnant?

 

 

 

 

 

 

 

 

 

 

 

 

 

Using birth control pills ____________________

Going through menopause?

Post-menopausal?

 

 

 

 

 

(Name of Prescription)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESCRIPTION/ NON PRESCRIPTION MEDICATIONS

 

MARK HERE IF NONE

VERIFIED BY

 

 

(Use continuation page if necessary)

 

 

 

 

EXAMINER

11. List all medications and herbal supplements/remedies that you are currently taking.

 

Name:

For what Condition?

Dose/Frequency of use:

A)

B)

C)

D)

E)

F)

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GENERAL MEDICAL INFORMATION - PRESENT SYMPTOMS

12. Mark symptom(s) that you NOW experience or HAVE RECENTLY experienced.

MARK HERE IF NONE

 

 

VERIFIED BY EXAMINER

GENERAL

 

HEAD & NECK

Neck pain________________________________________

Weight loss_______ Lbs. Over what time period? _________

Neck lump/swelling_________________________________

Weight gain_______ Lbs. Over what time period? _________

Headache________________________________________

Loss of appetite ____________________________________

Facial pain _______________________________________

Always hungry _____________________________________

Jaw pain_________________________________________

Always thirsty ______________________________________

 

 

Frequent urination___________________________________

 

 

Fatigue ___________________________________________

 

SALIVARY

Faint easily ________________________________________

Need liquid to swallow dry foods______________________

Night sweats_______________________________________

_______________________________________________

Bleed easily _______________________________________

Mouth feels dry when eating a meal____________________

Bruise easily_______________________________________

_______________________________________________

CARDIOVASCULAR

Difficulties swallowing any foods______________________

_______________________________________________

Shortness of breath with exertion_______________________

Sense of too little saliva_____________________________

Racing or irregular heart beat__________________________

Sense of too much saliva____________________________

Swollen ankles _____________________________________

 

 

Cold ankles/feet ____________________________________

 

 

Chest pain/angina___________________________________

 

EYES

 

Vision changes____________________________________

RESPIRATORY

Dry eyes_________________________________________

Coughing spell_____________________________________

 

 

Wheezing_________________________________________

 

EARS

Use 2 or more pillows to sleep_________________________

 

Hearing loss______________________________________

 

MUSCULOSKELETAL_

Ringing ears______________________________________

Joint pain _________________________________________

Earaches ________________________________________

Swollen joints ______________________________________

Pressure/stuffiness in ears___________________________

Muscle cramping____________________________________

 

 

SKIN CHANGES

 

NOSE/THROAT

Congested/runny nose______________________________

 

Skin problems_____________________________________

Nose bleeds ______________________________________

Nail changes______________________________________

Nasal obstruction __________________________________

NEUROLOGICAL

Sore throat _______________________________________

Hoarseness/voice changes __________________________

Numbness/tingling__________________________________

Mouth breathing/ snoring ____________________________

Paralysis/weakness_________________________________

 

 

Memory changes___________________________________

 

 

Smell/taste changes_________________________________

 

PAIN

Difficulty chewing___________________________________

Back pain________________________________________

Swallowing changes_________________________________

Other pains ______________________________________

Speech changes____________________________________

 

 

Dizzy spells or fainting_______________________________

 

BEHAVIORAL

GASTROINTESTINAL

Stress___________________________________________

Sleep difficulties___________________________________

Indigestion ________________________________________

Feel depressed ___________________________________

Reflux/heartburn____________________________________

 

 

Nausea/vomiting____________________________________

Feel agitated/anxious_______________________________

Bowel problems____________________________________

Other ___________________________________________

 

____________________________________________

 

____________________________________________

FAMILY MEDICAL HISTORY MARK HERE IF NO ONE IN YOUR FAMILY

VERIFIED BY

HAS EVER HAD ANY OF THE PROBLEMS LISTED BELOW

EXAMINER:

13. Darken the circle beside medical problems that have been present in your parents, brothers/sisters, or close relatives.

Genetic (inherited) disease _________________________

Bleeding disorders ____________________________

Liver/kidney disease______________________________

Tuberculosis___________________________________

Immune system disease ___________________________

Neurologic disease______________________________

Diabetes________________________________________

Other (include cancer)____________________________

 

 

 

 

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MEDICAL HISTORY - PAST AND PRESENT ILLNESS

14.Darken the circle for illnesses that you CURRENTLY HAVE or HAVE HAD IN THE PAST

Cancer & Neoplastic Disease

Cancer_______________________________________

Leukemia/Lymphoma ___________________________

Genetic (inherited) Disease

Type_________________________________________

Immune System Disorder

Rheumatoid arthritis_____________________________

Lupus erythematosus____________________________

Sjogren’s Syndrome_____________________________

Other_________________________________________

Hormonal or Metabolic Disorders Diabetes______________________________________

Thyroid problems _______________________________

Adrenal insufficiency_____________________________

Other_________________________________________

Heart/Blood Disorders

High blood pressure_____________________________

Artherosclerosis________________________________

Heart attack ___________________________________

Coronary artery disease__________________________

Heart murmur__________________________________

Heart valve problems____________________________

Bleeding disorder_______________________________

Anemia_______________________________________

Other ________________________________________

Neurological Disorders

Epilepsy/Seizures_______________________________

Neuralgia _____________________________________

Stroke________________________________________

Other_________________________________________

Chronic Pain

Back _________________________________________

Abdominal_____________________________________

Headache/Migraine _____________________________

Other_________________________________________

Head and Neck Conditions

Injury to face, jaws, neck _________________________

Concussion____________________________________

Radiation treatment _____________________________

Temporomandibular joint disease __________________

Salivary gland problems__________________________

Sinusitis ______________________________________

Glaucoma_____________________________________

Other ________________________________________

MARK HERE IF NONE

VERIFIED BY EXAMINER

Gastrointestinal Disorders

Acid-reflux /Heartburn______________________________

Ulcer/Gastritis____________________________________

Irritable bowel syndrome/Colitis ______________________

Other___________________________________________

Lung/Airway Disorders

Emphysema_____________________________________

Pneumonia______________________________________

Bronchitis_______________________________________

Asthma_________________________________________

Tuberculosis_____________________________________

Sleep Apnea_____________________________________

Other___________________________________________

Skin Disorders

Skin cancer______________________________________

Skin infections ___________________________________

Other___________________________________________

Other Major Organ Disease

Kidney disease___________________________________

Liver disease_____________________________________

Organ transplant__________________________________

Spleen surgery___________________________________

Other __________________________________________

Infectious Diseases

Rheumatic fever__________________________________

Strep Throat_____________________________________

Mononucleosis___________________________________

Hepatitis________________________________________

Sexually-transmitted diseases_______________________

HIV/AIDS _______________________________________

Other___________________________________________

Behavioral Conditions

Psychiatric illness_________________________________

Anxiety/Panic attacks______________________________

Depression______________________________________

Suicide attempt or thoughts _________________________

Other___________________________________________

Habits/Addiction

Drug abuse______________________________________

Alcohol abuse____________________________________

Other Conditions

Disabled ________________________________________

Prosthetic valve __________________________________

Prosthetic joint ___________________________________

DOCTOR’S/ STUDENT’S USE

(Please write comments about positive responses on lines adjacent to item and use this space as needed):

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15.CONSUMPTION OF BEVERAGES AND OTHER SUBSTANCES

a.Number of caffeinated beverages you drink in a day:

 

0

1-2

3-5

5+

b. Number of alcoholic beverages you drink in a week:

 

0

1-2

3-5

6-10 10+

d. Number of carbonated beverages a day:

 

0

1-2

3-5

5+

c. Currently using any street or recreational drugs?

No

Yes (Type?)________________________

 

 

MARK HERE IF NONE

 

 

VERIFIED BY EXAMINER

e.

Have you ever used tobacco?

No

Yes

 

If yes, what type:

 

 

 

 

Cigarette

Pipe/Cigar

 

Smokeless

f.

Do you currently use tobacco?

No

Yes

 

If yes, average number of uses per day: ______

 

For how many years? ____

 

 

16.DENTAL HISTORY : Darken the circle beside items that describe your past dental problems and dental care.

Regular dental care

Occasional dental care

Wisdom tooth extractions

Orthodontics

Gum disease (pyorrhea, gingivitis or periodontal disease)

Treatment for jaw trauma/fracture (Type?)_______________________________________________________________

Had an adverse reaction to dental treatment (Please describe)_______________________________________________

Dental fears or anxiety______________________________________________________________________________

17. Rate your ORAL HEALTH in general.

Excellent

Very Good

Good

Fair

Poor

18. How good a job do you feel you are doing in taking care of your oral health?

Excellent Very Good Good Fair Poor

19. Date of last regular dental visit: ___ ____ Name and address of dentist: _____________________________

Month Year

_____________________________

 

_____________________________

FAMILY DENTAL HISTORY

20. Darken the circle beside oral problems that have been present in your parents, brothers/sisters, or close relatives.

Caries

Gum disease (pyorrhea, gingivitis or periodontal disease)

Dry Mouth

TMJ disorder

DOCTOR’S/ STUDENT’S USE

Additional Notes or Comments:

Patient’s Signature_______________________________________________Date____________

Reviewed by (Student)___________________________________________________

Date____________

Reviewed by (Faculty) ___________________________________________________

Date____________

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