Medical History Form

Stan Brown, M.D.

family medicine

Perimeter Primary Care
Medical History

(X)	Personal History	Details
	High Blood Pressure
	High Cholesterol
	Heart Condition
	Diabetes
	Stroke
	Migraine
	Ulcer/ Reflux/ GERD
	Hepatitis (A, B, or C)
	Arthritis
	Allergies (seasonal, year round)
	Asthma
	Bronchitis/ Pneumonia
	Kidney Stones
	Recurrent urinary infections/ Prostatitis
	Sexual Difficulty
	Thyroid disorder
	HIV
	Cancer (what type & when diagnosed)
	Skin Condition
	Mental Condition

	Other illnesses:
	Hospitalizations:

Weight: Now______ 1 Year Ago_____ Max Weight_____ Max When_______

Date of last Physical Exam _________ Where was it done _______________

Allergies (medications or foods)	type of reaction

Medications (name of medication / dose / frequency taken)

Surgeries	date/ location/ surgeon

(x)	Family History	relationship / age at diagnosis
	Breast cancer
	Colon cancer
	Lung Cancer
	Prostate cancer
	Diabetes
	High Blood Pressure
	Heart Disease/Attack
	Stroke
	Thyroid disorder
	Mental Condition
	Neurological disorder
	Other:

Social History

Education:___years in high school, ___years in college, ___years post grad

Have you ever lived outside the United States? Yes No
If yes, location and when: _________________________

Children: names and month / year of birth

_____________________________________________________________________________________________________________

(X)	Habits	What specifically? / frequency? / quantity?
	Tobacco
	Alcohol
	Illegal Drugs
	Exercise

Female History
Date of last pap smear__________ (normal / abnormal)
History of abnormal pap smears? yes / no    If so, when____________
Date of last mammogram__________ (normal / abnormal)
History of abnormal mammograms? yes / no   If so, when__________
Total number of pregnancies_________ Number of live births_______
Are your cycles regular? yes / no
Date of last menstrual period__________

Do you have an Advance Directive? yes / no
(An Advance Directive is a document that states your wishes regarding medical treatments should you have a serious illness or accident and are unable to speak for yourself.)