Plymouth Family Physicians

Medical History

The following form requests medical history that will be used for your healthcare purposes. Please complete the form below. Filling out this form electronically will be most efficient. If you prefer to use a Word document please send or bring the electronic file if possible. This form is also available in PDF format if you prefer to print it out and complete it manually.

Date

Name (required)

E-mail Address

Age

Occupation

Marital Status

Spouse's Name

Age

Occupation

Children (names, year of birth:)

Previous Medical History: (Please list age or year if possible)

Childhood illnesses:

Last tetanus shot:

Hospitalizations or surgeries:

Date of last colon cancer screening:

Health Habits

Do you use tobacco? Yes No

How much per day?

For how many years?

Do you drink alcohol? Yes No

How much per week?

How much caffeine per day?

Check or list any of the following problems you have had:

Weight gain/loss
Highest adult weight lowest

Fever, chills, night sweats

Headaches, head injuries, concussion, other

Eye problems (wear contacts or glasses?) other

Ear problems, hearing loss, ringing, pain, other

Thyroid problems or x ray treatment to neck or chest

Breast masses, breast discharge, breast pain
Date of last mammogram:

Breathing problems, shortness of breath, asthma, bronchitis, pneumonia, emphysema, other

Heart disease, high blood pressure, rheumatic fever, chest pain, palpitations or skipped beats, heart murmur

Date of last cholesterol check?

Results of last cholesterol check?

Heartburn, swallowing difficulty, ulcers, gallstones, food intolerance, constipation, diarrhea, bloody or black bowel movements, abdominal pain, hernia

Kidney or bladder infection, loss of urine control, pain with urination, kidney stones, poor urine stream, blood in urine

Muscle pain, joint pain or swelling, broken bones, dislocations, muscle weakness

Seizure, loss of coordination, tremors, speech problems, memory loss, numbness, tingling

Skin changes, mole change, skin infections, hair loss, psoriasis

Bleeding from any site, clotting problems, bruising easily, transfusion
If yes to transfusions, what year?

Depression, poor sleeping, appetite problems, panic attacks, suicidal thoughts or attempts

Concerns about sexuality or sexual function?

Males:

Prostate enlargement or infection/discharge from penis/herpes, venereal warts or other sexually spread diseases/sexual problems/lumps in testes/swelling in scrotum/infertility/birth control questions

Females:

Age at first period

Last normal period

Periods that are heavy, irregular, short, painful, missing, bleeding between periods

Herpes, venereal warts, other sexually spread infections, infertility, sexual problems?

Pregnant?

Yes No Not sure

Age at first pregnancy

Month and year of last pap smear

Any abnormal pap smears? Yes No

Number of pregnancies	Full term births
Premature	Miscarriages
Abortions	Living children

Birth control questions? Yes No

Family Medical History

Family Name

Have any family members had any health problems? Please consider any of the following: diabetes, heart disease, heart attacks, heart surgery, high blood pressure, stroke, high cholesterol, cancer, tuberculosis or other lung disease, ulcers or liver disease, kidney stones, arthritis, severe depression or suicide

Father's current age or age at death

Father's health problems

Mother's current age or age at death

Mother's health problems

Did your mother have to take medication to prevent miscarriages? Yes No Not sure

Please list all your brothers, sisters and children, along with any health problems they may have:

Any health problems of grandparents, aunts, uncles, and/or cousins?

Any other health concerns you would like to discuss?

Please keep in mind the time limitations of your appointment. It may be best to schedule additional follow-up appointments in order to adequately address your concerns.

I understand that the information on this page will be sent to Plymouth Family Physicians, S.C. and that this submission is not secure. If you are concerned, don't click the Submit button and PRINT THIS FORM or SAVE IT AS A FILE after completing it. You can then mail it or drop it off at the office. If you choose to complete this form at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.