Comprehensive Medical History: Adult Patient
 Please fill out this form, print it, and take it with you to the physician's office. Do not scroll past the borders of boxes or your
information will not show on the printout.   To protect your privacy, the information you enter will not be saved. 

 Surname First name  Middle initial

Provincial Health Number       Version Code:
Date of birth DD/MM/YYYY         
Sex (select by clicking) Male Female Marital Status  

Address

Number and Street
City, Town or Village
Province, Territory or State   
Postal/ZIP code   
Country
Home Tel
Work Tel
Fax
Cell
Other

Email

Referral Source: Patient  Friend Another Doctor Other

Place of Birth:

Religion (optional)

Education

Highest level completed
Where
What Language

Occupation


If other:

Present work activity
Past Work Activities (1)
Date Work Ended
Past Work Activities (2)
Date Work Ended
Hazards of your work

Military Service: 

Where?
How long?
Rank?
Department

List your current physicians

SPECIALTY

NAME

Your last physical examination

Date
Physician:

(Women only) 
Enter the date of your last gynecological examination and the physician who saw you.
(For further Gynecologic History, see below.)

Date
Physician:

Have you ever gone to an Emergency Room (ER) for treatment in the last year? Yes No
How many times in the past year?

List the reason and when you made each ER visit

MONTH

REASON

Have you ever stayed in the hospital overnight during the past year? Yes No
How many times in the past year?
List the reason and when you stayed overnight

MONTH

REASON

Psychosocial History

Describe your job satisfaction
What are your career goals?   

Do you smoke? Yes No Select which products you use :

PRODUCT SELECT IF USED HOW MUCH NUMBER OF YEARS
Cigarettes Used
Cigars Used
Pipes Used
Chewing Tobacco Used

Do you drink alcohol? Yes No Select which products you use and amounts:
Beer Yes No Amount
Wine Yes No Amount
Liquor Yes No Amount

Do you use recreational drugs?  Yes No
If yes, indicate which ones: Cannibas  Yes No    Hash Yes No   
Peyote Yes No Mushrooms Yes No Anabolic Steroids Yes   No  

Do you use mood altering drugs?  Yes No
If yes, indicate which ones:
Cannibas  Yes No     Ecstasy Yes No Cocaine Yes No
Heroin Yes No
Other Yes No

Do you drink coffee? Yes No  Number cups per day

Do you exercise regularly?  For how long?  
Type of exercise

Family History: If there anyone in your family with heart disease, high blood pressure,
diabetes, kidney, cancer, tuberculosis, fibrocitis, stroke, arthritis, anemia, headaches,
mental illness, or other illnesses, list them below.

CONDITION

RELATIONSHIP


Accident History:

MVA's
Industrial related
Other

Past Surgical History: List Operations (include childhood tonsils, appendix).

DATE CONDITI0N HOSPITAL

Have you ever had a general anesthetic problem?  Yes No
Any blood transfusion(s) Yes No
If yes, explain

Have you had any blood transfusions Yes   No
If so, when, where, and how many units?



Describe in a list your Past and Present Medical History (in particular, indicate hospital admissions)
e.g., Diabetes/ thyroid, Blood disorder, High blood pressure, Peptic ulcer, Liver disease, High cholesterol,
Sexual transmitted diseases, Cancer, Other,  (do not scroll past the borders):

Sexual History

Have you been sexually active within the past year?  Yes No
If so, state the number of partners:  One More than one
Sexual orientation:  Heterosexual (opposite sex) Gay Bi-sexual (both sexes)
Do you  have a history of Sexually Transmitted Disease?  Yes No
If yes, please specify (do not scroll past the borders)

Review of Organ Systems

General: weight loss  weight gain  fever  rigors chills  weakness anorexia
Skin:  rashes  lumps  changes in hair or nails dry sweaty rash itchy red pain 
ulcerations callosities change in colouration scars tatoos  
body piercing-specify
Head:  headache  head injury
Eyes: glasses contact lens cataracts glaucoma strabismus red eye eye pain 
photophobia blurred vision diminished (lost) vision running eyes  dry eyes 
Ears: decreased hearing hearing aid vertigo ringing in ears (tinnitus) /ear pain (otolgia) 
discharge 
Nose and sinuses: pain swollen discharge nosebleed (epistaxis) frequent colds nasal stuffiness
hay fever  sinus trouble
Mouth and throat: dentures caps bridge toothache frequent sore throat bleeding gums 
last dental examination hoarseness gums trauma bad breath burning mouth 
Neck:  lumps in neck  "swollen glands" goiter pain in the neck
Breasts:  lumps pain discharge check if you self-examine? 
--date of last mammogram (women only)
Respiratory: cough phlegm (sputum) green sputum (purulent) clear foamy sputum (mucoid) 
spitting up blood (hemoptysis) shortness of breath wheezing asthma bronchitis emphysema 
pneumonia tuberculosis pleurisy --date of last tuberculin (TB) skin test:
 --date of last chest X-ray
Cardiovascular: chest pain shortness of breath (dyspnea) high blood pressure rheumatic fever 
heart murmur -- date of last electrocardiogram (ECG) or other heart tests   swollen legs
  dizziness loss of consciousness (syncope) weakness slow heart rate (bradycardia) fast heart rate
(tachycardia) abnormal sensation of HR- skipped beats (palpitations) 
Peripheral Vascular (Circulation): varicose veins blood clot (thrombophlebitis) 
calf pain or cramps with walking (claudication) cold or painful extremities
Gastrointestinal: trouble swallowing (dysphagia) heartburn indigestion  
change in pattern of bowel movements hepatitis or other liver disease gall bladder food intolerance
  stomach ache chest pain (burning) abdominal pain nausea vomiting diarrhea 
vomiting up blood (hematemesis) passing blood per rectum in stools (hematochezia - bright red blood
melena - black tarry stools) hemorrhoids colitis weight loss greenish pale skin (jaundice) 
yellow eyes (conjunctiva - scleral icterus) gas (belching, farting) abdominal bloating fullness
Urologic: frequent urinating sense of urgency urinating excessively at night (nocturia) 
pain or difficulty urinating (dysuria) blood in urine (hematuria) foul odored urine (stranguria) 
history of hernias pain or bleeding during or following intercourse
Male Genital System:  prostate disease pain in testis lump(s) in testis discharge or sores from penis
difficulty initiating or maintaining an erection (erectile dysfunction) pain or bleeding during or following intercourse
circumsized
Gynecologic (female genital) system: 
Onset of periods (menarche) Last menstrual period
Periods intervals : regularity   frequency duration
Flow: heavy medium light 
cramps PMS bleeding during intercourse
Number of pregnancies: Number of deliveries: 
Number of miscarriages/abortions 
Contraception: pill IUD diaphragm sponge/foam Norplant injection Depo Provera
vaginal discharge vaginal itching  rash mal-odour 
Sexual difficulties
Musculoskeletal: joint pain (arthralgias) joint stiffness arthritis gout back problems 
muscle pains (myalgias) limitation in functions worse during: PM or AM related to activity 
trauma/ fever joint swelling joint deformed 
Neurologic: headache fainting blackouts seizures weakness numbness paralysis 
shaking (tremor) spasms nerve pain altered personality confusion dementia poor memory
Psychologic: nervousness tension high stress depressed poor sleep (insomnia) 
diminished libido increased libido mania psychosis confusion poor judgement poor memory 
poor insight delusional hallucinations hear voices feels out of control impusive self destructive
suicidal feelings or tendencies feelings to hurt or harm others despondent withdrawn helpless 
hopeless frustrated angry rage history of substance abuse criminal record-specify
Endocrine (Hormones): thyroid problem heat or cold intolerance excessive sweating diabetes 
excessive thirst excessive hunger excessive urination

(Women only): Menopause? no yes
Date of last bone mineral densiometry for osteoporosis
Supplements: Vitamin D Calcium Estrogen  Evista Didrocal Fosamax other

Hematologic: anemia thallassemia easy bruising easy bleeding (gums, nose, rectum, urine)
medications: blood thinners aspirin Vitamin C E garlic
Past transfusions:

List any allergies you have to food or medications (Summarize)

Have you ever had an anaphylactic reaction (turning red, difficulty breathing, generalized swelling up)? Yes No

Present Prescription Medication (include contraceptives, inhalers, patches, creams):

Drugs, dosage, and how often you take them.


To avoid errors, bring in any medications with you in their original bottles.

                                                             Adult Vaccine History

Enter the date and name the physician giving you the following vaccines:

DATE PHYSICIAN
Tetanus booster
Diptheria  
MMR 
Hepatitis B
Flu shot
Pneumovax
Rubella (women) 
Hepatitis A

 

 

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