Medical History Form 3Medical History Form 3Medical History Form 3
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Medical History Form
Primary Physician

Last, First, Middle
Today's Date

Male

D.O.B. & Age

Employer

Statement of Present Health:

Female

Job Title

Medications: All prescription, non-prescription, vitamins, home remedies, or herbal medication
Name
Dose (ex: mg/pill)
How often?

Excellent

Good

Fair

Poor

Date medication started

Medication Allergies

Social History
YES

NO
Marital Status:
single
Spouse / Partner Name:

married

divorced

widowed

other

Who lives at home with you?
Do you have an end of life directive? (Living will, medical power of attorney, etc.)
Tobacco Use: (type & amount per day)

Date quit

Alcohol Use: (type &frequency)
Is alcohol a concern for you or others?
Caffeine Intake: None:
Diet: (please rate)

Good:

Coffee/Tea
Fair:

Cups/Day

Soda

Cups/Day

Poor:

Seat Belt Use:
always ___
occasionally ___
never ___
Are you, a relative, close friend, or companion who will be involved in your visit deaf or hard of hearing?

Current Family Health Stat