Medical History Form Printable PDF Details

The Medical History form is a cornerstone document in the patient care process, serving as a bridge between past medical events and current health assessments. At its core, it systematically enumerates a comprehensive list of potential health conditions, chronic illnesses, allergies, and personal habits that could significantly influence both diagnosis and treatment plans. Key aspects include identifying the patient's general health status through a categorical selection—ranging from excellent to poor—and the detailing of any past surgeries, hospitalizations, or chronic conditions that might affect ongoing medical treatments. It goes beyond mere listing, encouraging patients to disclose their current medication regimen, including over-the-counter drugs, supplements, and vitamins, to preempt any adverse drug interactions or contraindications. Importantly, the form prompts updates on any new health developments or modifications in medication, ensuring that the medical record remains accurate and up-to-date. In essence, the Medical History form acts as a crucial narrative tool, capturing the patient's health journey, fostering a holistic understanding, and facilitating tailored healthcare strategies.

QuestionAnswer
Form NameMedical History Form Printable
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesprintable family medical history forms, patient family history form, blank medical history form printable, family medical history forms printable

Form Preview Example

MEDICAL HISTORY

Paient Name ________________________________________________ Nickname ____________________ Age ________

Name of Physician/and their specialty _____________________________________________________________________

Most recent physical examinaion ________________________________ Purpose _________________________________

What is your esimate of your general health? Excellent Good Fair Poor

DO YOU HAVE OR HAVE YOU EVER HAD:

YES

NO

YES NO

1.

hospitalization for illness or injury______________________

 

26.

osteoporosis/osteopenia (i.e. taking bisphosphonates) __

2.

an allergic reaction to

 

27.

arthritis, rheumatoid arthritis, lupus _________________

 

aspirin, ibuprofen, acetaminophen, codeine

 

28.

glaucoma______________________________________

 

penicillin

 

29.

contact lenses __________________________________

 

erythromycin

 

30.

head or neck injuries _____________________________

 

tetracycline

 

 

 

31.

epilepsy, convulsions (seizures) _____________________

 

sulfa

 

 

 

32.

neurologic disorders (ADD/ADHD, prion disease) _______

 

local anesthetic

 

 

 

33.

viral infections and cold sores ______________________

 

fluoride

 

 

 

34.

any lumps or swelling in the mouth__________________

 

metals (nickel, gold, silver, ____________)

 

 

 

35.

hives, skin rash, hay fever__________________________

 

latex

 

 

other _____________________________________

 

36.

STI / STD ______________________________________

3.

heart problems, or cardiac stent within the last six months __

 

37.

hepatitis (type ___) ______________________________

4.

history of infective endocarditis _______________________

 

38.

HIV / AIDS _____________________________________

5.

artificial heart valve, repaired heart defect (PFO) __________

 

39.

tumor, abnormal growth__________________________

6.

pacemaker or implantable defibrillator _________________

 

40.

radiation therapy________________________________

7.

artificial prosthesis (heart valve or joints) ________________

 

41.

chemotherapy, immunosuppressive_________________

8.

rheumatic or scarlet fever____________________________

 

42.

emotional problems _____________________________

9.

high or low blood pressure___________________________

 

43.

psychiatric treatment_____________________________

10.

a stroke (taking blood thinners) _______________________

 

44.

antidepressant medication ________________________

11.

anemia or other blood disorder _______________________

 

45.

alcohol / street drug use __________________________

12.

prolonged bleeding due to a slight cut (INR > 3.5) _________

 

ARE YOU:

13.

emphysema, shortness of breath, sarcoidosis ____________

 

46.

presently being treated for any other illness ___________

14.

tuberculosis, measles, chicken pox_____________________

 

47.

aware of a change in your health in the last 24 hours

15.

asthma__________________________________________

 

 

(i.e. fever, chills, new cough, or diarrhea) ______________

16.

breathing or sleep problems (i.e. sleep apnea, snoring, sinus)

 

48.

taking medication for weight management (i.e. fen-phen)

17.

kidney disease ____________________________________

 

49.

taking dietary supplements________________________

18.

liver disease ______________________________________

 

50.

often exhausted or fatigued _______________________

19.

jaundice _________________________________________

 

51.

experiencing frequent headaches___________________

20.

thyroid, parathyroid disease, or calcium deficiency ________

 

52.

a smoker, smoked previously or use smokeless tobacco _

21.

hormone deficiency ________________________________

 

53.

considered a touchy person _______________________

22.

high cholesterol or taking statin drugs __________________

 

54.

often unhappy or depressed_______________________

23.

diabetes (HbA1c =_______)__________________________

 

55.

FEMALE - taking birth control pills ___________________

24.

stomach or duodenal ulcer __________________________

 

56.

FEMALE - pregnant ______________________________

25.

digestive disorders (i.e. celiac disease, gastric reflux) _______

 

57.

MALE - prostate disorders _________________________

Describe any current medical treatment, impending surgery, geneic/development delay, or other treatment that may possibly afect your dental treatment. (i.e. Botox, Collagen Injecions)

________________________________________________________________________________________________________________

List all medicaions, supplements, and or vitamins taken within the last two years

Drug

 

Purpose

 

Drug

 

Purpose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ask for an addiional sheet if you are taking more than 6 medicaions

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Paient’s Signature ______________________________________________________________________ Date _____________________

Doctor’s Signature ______________________________________________________________________ Date _____________________

v 2012.2 Kois Center, LLC

To reorder, please visit: WWW.KOISCENTER.COM

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family medical history form template conclusion process detailed (part 1)

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