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    • International/Domestic Sevices
    • Medical Case Management
    • Medical Claims Management
    • Provider Networks/Services
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      • House Calls
      • Medical Escort Service
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Patient Medical History Form

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  2. Patient Medical History Form

Step 1 of 5

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MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
ALLERGY
ALLERGIC REACTION

Medications

MEDICATIONS (Please list ALL)
DOSE (Mg., pill, etc.)
TIMES PER DAY

If you need more room to list medications, please write them on a blank sheet of paper with the required information

Health Maintenance Screening Test History

CHOLESTEROL

MM slash DD slash YYYY
Abnormal Result?

COLONOSCOPY /SIGMOID

MM slash DD slash YYYY
Abnormal Result?

MAMMOGRAM

MM slash DD slash YYYY
Abnormal Result?

PAP SMEAR

MM slash DD slash YYYY
Abnormal Result?

BONE DENSITY

MM slash DD slash YYYY
Abnormal Result?
Vaccination History
Personal Medical History

DISEASE/CONDITION

CURRENT

PAST

COMMENTS

Alcoholism/Drug Abuse

Asthma

Depression/Anxiety/Bipolar/Suicidal

Emphysema (COPD)

Heart Disease

High Blood Pressure (hypertension)

High Cholesterol

Hypothyroidism/Thyroid Disease

Renal (kidney) Disease

Migraine Headaches

Stroke

Surgeries

TYPE (specify left/right)

DATE

LOCATION/FACILITY

Women’s Health History

Family Medical History

Untitled
Mother
Father
Brother
Sister
Child
MGM
MGF
PGM
PGF
Other:

Social History

Occupation (or Prior Occupation)
If employed, do you work the Night Shift?
Marital Status(check one)
Do you have children?
TOBACCO USE
Smoke Cigarettes?

(If you never smoked, please move to Alcohol /Drug Use)

Current:
Past:
Other Tobacco (check one):
ALCOHOL/DRUG USE
Do you drink alcohol?
drink_alcohol_second
Do you use marijuana or recreational drugs?
Have you ever used needles to inject drugs?
Have you ever taken someone else’s drugs?

Other Health Issues continued...

Sexual Activity
Sexually involved currently
(If no sexual history, please continue to exercise)
Sexual partner(s) is/are/have been
Birth control method
Exercise
Do you exercise regularly?
(If you answered no, please move to sleep)
SLEEP
DIET
How would you rate your diet?
Would you like advice on your diet?
SAFETY
Do you use a bike helmet?
Do you use seat belts consistently?
Working smoke detector in home?
If you have guns at home, are they locked up?
Is violence at home a concern for you?
Have you completed an Advance Directive for Health Care (ADHC), Living Will, or Physical Orders for Life Sustaining Therapy (POLST)?

Other Providers/Specialists

SPECIALIST
NAME
LAST VISIT
Cardiology
Gastroenterologist (GI)
OB/GYN
Neurology
Pulmonary

Additional Information

Have you traveled outside of the country in the last 30 days?
Have you served in the military?
Were you deployed?

Review of Systems

✔ CHECK ALL THAT APPLY
CONSTITUTION
CARDIOVASCULAR
SKIN
HEAD, EAR, NOSE & THROAT
GASTROINTESTINAL
ALLERGY/IMMUNO
EYES
ENDOCRINE
NEUROLOGICAL
RESPIRATORY
GENITOURINARY
HEMATOLOGIC
MUSCULAR
PSYCHIATRIC
MM slash DD slash YYYY
MM slash DD slash YYYY
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