P R I M E C A R E

Loading

Information

Appointment
flag
logo-img
Book Online

Health and Medical History Form

  • Home
  • / Forms
  • / Health and Medical History Form
PRIMECARE 360

Health and Medical History Form

 

First Name
Last Name
Date Of Birth
Address
City
State / Zip
Home Phone
Cell Phone
Email Address

Personal History

Cardiovascular
Digestive
Endocrine
Integumentary (Skin)
Nervous
Lymphatic
Genitourinary
Genitourinary
Respiratory
Reproductive
Musculoskeletal

Number of Sugeries

Surgery
Year
Complications
Surgery
Year
Complications
Surgery
Year
Complications
Surgery
Year
Complications
Surgery
Year
Complications
Surgery
Year
Complications

Number of Hospitalization

Hospitalization
Year
Complications
Hospitalization
Year
Complications
Hospitalization
Year
Complications
Hospitalization
Year
Complications
Hospitalization
Year
Complications
Hospitalization
Year
Complications

Immunizations : Please list the vaccine and date received

Covid
Booster(s)
Tentus
Influenza
Pneumonia
Shingles

Family History : Please list medical conditions of each family member

If the person is living, please list age, if deceased, please list age of death and cause if known.

Family Member Conditons Age Deceased Cause of Death
Mother
Father
Maternal Aunts / Uncles
Paternal Aunts / Uncles
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Is there family history of any forms of cancer? (Please list what kind and your relationship)
Are there any other things you would like us to know about your family history

Social History

What is your relationship status?
Do you have any children? If so, please age, sex, and medical conditions, if any
Are you employed? If so, where?
Work from home?

Do you do any of the following? If so, please specify whether a past or current use, and for how long.

Current Use? Past Use? If past use, what kind and how long go did you quit?
Cigarettes, cigars or smoked tobacco
Vape Products
Smokeless / Oral Tobacco
Caffeine [coffee, tea, soda,etc.]
Alcohol
Drug Use
Marijuna Use