Health History Form

COMCARE New Patient Health History Form
Thank you for providing the following information.

Date _________________ Name: _____________________________________________ DOB______________Age____________

_____________________________________ ___________________________________________ Sex______________________
(city of Residence) (birthplace)

PLEASE LIST ALL MEDICINES WITH DOSAGE YOU ARE NOW TAKING….PLEASE BRING ALL MEDICINES WITH YOU TO YORU APPOINTMENT

1. 7.

2. 8.

3. 9.

4. 10.

5. 11.

6. 12.

PLEASE BRING ALL MEDICINES WITH YOU TO YOUR APPOINTMENT!!

PLEASE LIST ALL VITAMINS & HEALTH FOOD SUPPLEMENTS YOU ARE NOW TAKING

1. 4.

2. 5.

3. 6.

PLEASE LIST ANY ALLERGIES YOU HAVE TO MEDICATIONS AND WHAT THE REACTION WAS:
Medicine Type of Reaction
1.

PLEASE LIST ALL OPERATIONS/HOSPITALIZATIONS YOU HAVE HAD:

Operation/Illness:	Date:	Hospital:	Doctor:

IMMUNIZATIONS:

VACCINE:	Last Date Given:
Tetanus
Flu Vaccine
Pneumonia Vaccine
Hepatitis B
TB Skin Test
Childhood Immunizations	Up to date: Yes No

Have you suffered any serious injuries (describe)? _________________________________________
__________________________________________________________________________________
Have you had any blood transfusions? Yes No

PAST MEDICAL HISTORY
Serious illnesses now or in the past? (please check)
Headaches _____________                                         Diabetes______________
Elevated Blood Pressure ________________               Thyroid Problem ________________
Heart Disease _________________                            TB ________________
Anemia _________________                                      Stomach Problems _______________
Lung Disease _____________________                                 Colon Trouble _________________
Ulcers ________________                                         Other __________________
Elevated Cholesterol ____________________
Cancer History (please check any that apply)                  Colon _____ Breast _____   Other _____
____________________________________________________________________________________________

FAMILY HISTORY
Father—age _______ If deceased, date of death _________ cause ______________________
Please list any other diseases:____________________________________________________
Mother-age _______ If deceased, date of death __________ cause ______________________
Please list any other diseases: _______________________________________________________
Brothers & sisters (list age & if deceased, note cause and date of death, also include any other diseases)
___________________________________________________________________________________
Please list any other family diseases: ______________________________________________

SOCIAL HISTORY
Marital Status ___________ Number of Children ___________ Occupation ___________________
If a woman-number of pregnancies ______________
Tobacco use? (please check) Abstain ______ Low _____ Moderate ____ High ____
Alcohol use? (please check) Abstain ____ Low ____ Moderate ____ High ____