Download & Print Form


* Indicates Requied Fields

Patient Name:

// Male Female
Heart Disease COPD/Emphysema/Bronchitis
Previous Heart Attack / Chest Pain Asthma  
Congestive Heart Failure Other Lung Disease
Heart Valve Disorders  
Heart Rhythm Problems Cancer
High Blood Pressure  
High Cholesterol / Lipids Gall Bladder Disease
History of Stroke  
Diabetes Bowel Disease
Peripheral (Leg) Vascular Disease  
Epilepsy / History of Seizures Hepatitis / Liver Disease
Anemia Kidney / Bladder Disease
Stomach Ulcer  
Clotting / Bleeding Disorder Thyroid Disease





Procedure | Year

Gallbladder (Cholecystectomy) Coronary Artery Bypass Thyroid
Appendix (Appendectomy) Other Heart Surgery Breast Biopsy/Mastectomy
Hernia Repair (any) Lung Surgery Tonsillectomy
Stomach/Bowel Surgery Joint/Back Surgery Plastic Surgery
Rectal/Hemorrhoid Hysterectomy/C-Section Skin Surgery
None Latex

Social History:

Single Married Divorced Widowed
Yes No
Yes No
Former Smoker
Yes No
Yes No

Family History: Does anyone in your family have any of the following? If so, list your relation to them:

Breast Cancer Stroke Colon Cancer Epilepsy / Seizures Ovarian/Uterine Cancer
GallBladder Disease Melanoma Bleeding / Clotting History Prostate Cancer Diabetes
Lung Cancer Heart Disease Pancreatic Cancer Lung Disease Lymphoma / Leukemia
High Blood Pressure Thyroid Cancer High Lipids / Cholesterol Skin Cancer Hemorrhoids
Other Cancer (Type and Family Member) Other
Yes No
None Yes
No Yes

Please explain any “Yes” answers at the bottom of this page.

Weight Loss lbs Weight Gain lbs Fever/Chills
Last Colonoscopy (year) Last Flex. Sig. (year) Last stool occult blood test Diarrhea
Blood in stool Abdominal pain Heartburn Constipation
Headaches Weakness Dizziness Numbness / tingling
Glaucoma Cataracts Recent vision changes
Depression Trouble sleeping Schizophrenia Alcohol dependency
Drug dependency
Chest pain Irregular Heartbeat Shortness of breath Feet / leg swelling
Varicose veins
Painful urination Slow/frequent urination Infections Blood in urine
Kidney stones
Cough Trouble breathing Wheezing Pneumonia
Last pap smear Number of pregnancies Number of deliveries Venereal disease
Menstrual irregularities Menopause,age? Vaginal discharge
Last mammogram (date) Monthly self exams Lumps Nipple discharge
Menstrual irregularities Pains
Hearing loss Nose bleeds Gum problems Sore throat
Hoarseness Trouble swallowing
Easy bleeding or bruising Anemia Blood transfusion (year)
Last Prostate Exam (YR) Last PSA Test (YR) Prostate disease Testicular lumps, pain
Venereal disease
Fractures/dislocations Muscle pain/cramps
HIV / AIDS Hepatitis (A, B, or C?)
Rashes / dermatitis Changes in moles