HTML Preview Past Medical History Form page number 1.
Page 1 of 5
Patient Past Medical, Social &
Family History
INSTRUCTIONS: Complete the following information by
placing a check mark (√) in the appropriate boxes or by
PRINTING the requested information. DO NOT write in the
shaded areas labeled “For Medical Team Use Only.”
Today’s Date _________/_________/______________
(Month/Day/Year)
Patient Name
______________________________________________________
(Last) (First) (M.I.)
Social Security # ____ ____ ____-____ ____-____ ____ ____ ____
Date of Birth _______/_______/__________ Sex: Male Female
(Month/Day/Year)
Who completed this form? Patient Spouse Other (specify)
_______________________________________________________
Name (if other than patient)
_______________________________________________________
Past Medical History
Have you ever been hospitalized? No Yes
Have you had any serious injuries and/or broken bones? No Yes → Describe
_____________________________________________________
Have you ever received a blood transfusion? Unknown No Yes → Approximate year(s) ___________________________________________
Have you ever traveled or lived outside the United States or Canada? No Yes → When and where ______________________________________________
Have you received the following
IMMUNIZATIONS? If yes, indicate the approximate year it was last given:
Pneumococcal (for pneumonia) Unknown No Yes Year________ Measles Unknown No Yes Year________
Hepatitis A Unknown No Yes Year________ Mumps Unknown No Yes Year________
Hepatitis B Unknown No Yes Year________ Rubella Unknown No Yes Year________
Tetanus/Diphtheria within last 10 years Unknown No Yes Year________ Polio Unknown No Yes Year________
Influenza (flu) Unknown No Yes Year________
Have you ever had any of the following?
No Yes Describe the problem when appropriate For Medical Team
Use Only
1. Abnormal chest x-ray
2. Anesthesia complications
3. Anxiety, depression or mental illness
4. Blood problems (abnormal bleeding, anemia,
high or low white count)
5. Diabetes
6. Growth removed from the colon or rectum
(polyp or tumor)
7. High blood pressure
8. High cholesterol or triglycerides
9. Sexually transmitted disease
10. Stroke or TIA
11. Treatment for alcohol and/or drug abuse
12. Tuberculosis or positive tuberculin skin test
13. Cosmetic or plastic surgery