Print out this form to complete. Mail, fax, or bring the completed form to
the office.
Medical History
Patient’s name:___________________________________________
Age:______ Today’s date:________
Does the patient communicate in English? Yes___
No___ Is the patient able to read? Yes___ No___
Current medical concerns and symptoms:_____________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Previous surgeries and hospitalizations (include
dates):_________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Circle or list previously diagnosed medical
illnesses:
Hypertension
Diabetes
High cholesterol
Hypothyroidism/Hyperthyroidism/Goiter
Glaucoma/Cataract
Coronary disease/Heart attack
Congestive heart failure
Valvular heart disease
Cardiac arrhythmia
Emphysema/Chronic bronchitis
Asthma/Hayfever/Eczema
Peptic ulcers(duodenal/gastric)
GERD/reflux/acid indigestion
Hepatitis (type if known)_________________________
Stroke
Seizures
Anemia
Bleeding disorder
Clots in
legs/lungs (DVT/PE)
Cancer
HIV/AIDS
Tuberculosis
Obesity/Eating
disorder
Other illnesses:________________________________
Current medications (including birth control
pills and non-prescription drugs):____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Drug and Food Allergies:____________________________________________________________________
Additional History
Please circle or fill in your responses
Immunizations received:
Tetanus(most recently vaccinated in ____)
Influenza(most recently vaccinated in ____) Pneumovax(____)
Other
immunizations:__________________________________________________________
Do you use eyeglasses or contact lenses? Do you use eyeglasses or contact lenses?
Yes
No Hearing aides?
Eye doctor's
name:_____________________________________________________
For women: When was your last
mammogram?_______ When was your last Pap test?_______
Name of
gynecologist:__________________________________________________
For men age 50 and over: When was your last PSA blood
test screening for prostate cancer?______
Previous colon cancer screening with
colonoscopy or barium enema? Yes No If yes, year done:_____
Name of GI
specialist:__________________________
Do you smoke? Yes (average # of packs per day:____ starting
age____). Never smoked. Previously smoked but quit in ___
Do you drink alcohol? Yes (average # of drinks per day:__).
Occasionally (average # of drinks per month__). Never or rarely drink.
Do you usually wear your seat belt when in a
car? Yes No
Are you at risk for sexually transmitted
illnesses? Yes No Not sure
Do you have an exercise regimen to help stay
physically fit? Yes No
If yes, please describe your
routine:___________________________________________________________________________
Are you on any special type of diet? Yes
No If yes, please describe your dietary
regimen:__________________________________________________________________________
Have any of your close family members suffered
from hypertension, diabetes, heart attacks, stroke, cancer, or tuberculosis? If
so, please indicate details of the family medical history below:
Grandparents:____________________________________________________________________________
Father:__________________________________________________________________________________
Mother:__________________________________________________________________________________
Brothers/Sisters:__________________________________________________________________________
Children:_________________________________________________________________________________
Social History: Place
of birth:_______________ Marital status:__________ Number of children:_________
Occupation and place of
work:_______________________________________________________________
Special
interests/hobbies:__________________________________________________________________
________________________________________________________________________________________
Review of Systems
Have you recently had any of the
following symptoms? Please circle those symptoms which pertain to you. In the
space on the right side of the page, please try to describe the location,
duration, and severity of the symptom as well as the circumstances
under which the problem seems to occur.
Weight loss/weight gain
Fatigue/weakness
Fever/night sweats
Rash/itching
Lumps/bumps/change in mole
Headache/dizziness
Visual disturbance
Hearing loss/ringing in ears
Nasal congestion/sinus pain
Nose bleed
Throat pain/hoarseness
Swelling in the neck
Breast pain/lump/nipple discharge
Cough/sputum
Shortness of breath/wheezing
Chest
pain/palpitations
Abdominal pain/heartburn
Nausea/vomiting/diarrhea
Bloody or black tarry bowel movements
Pain on
urination/blood in urine
Difficulty starting or maintaining urine flow
Involuntary leakage of urine
Unusually frequent urination
Discharge from
penis or vagina
Problems with sexual functioning
Joint
pain/stiffness
Backache/muscle pain
Cold feet/hands
Cramps in legs with walking
Leg/ankle swelling
Fainting/blackouts
Numbness
Tremors
Confusion/memory difficulties
Localized weakness/paralysis
Nervousness/depression
Insomnia
Heat or cold intolerance
Excessive sweating
Excessive thirst, hunger, or
urination
Easy bruising or bleeding
For women only:
Number of pregnancies:
Number of deliveries:
Birth control method:
Last menstrual period:
Irregular or heavy periods?
Painful periods?
Mercer Internal Medicine, LLC
Reviewed by: JFA GN MY
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