Patient History

First Name

Last Name

Date of Birth

Age

Primary Care Provider

Referring Provider

Chief Complaint

How long?

Current Medication List (Include Medication Name, Dosage, & Frequency)

Drug Allergies - Medication & Reaction

Past Medical History

If cancer, what type?

Past Surgical History

If other, what type of surgery?

Past Hospitalizations (List below with dates and include child birth)

If yes cancer, type

Social History

Marital Status

Single

Married

Divorced

Widowed

Housing

House

Apartment

Mobile Home

Other

Exercise Regularly

Yes

No

Do you live with a smoker? Yes or No

Do you have problems with water leaks, wet spots, or mold in your home? Yes or No

Do you have pets in your home? Yes or No

Type

Amount

Do you consume caffeine? Yes or No

If yes, how many drinks per day?

Alcohol Usage

Currently Every Day

Currently Some Days

Former

Never

If currently every day amount and type:

If former, quit date?

If currently every day amount and type:

If former, quit date?

Prior or current recreational drug use. Yes or No

Other risk factors for HIV. Explain:

Occupation

Please check symptoms that patient is experiencing currently.

If other, please explain.

Endocrine

Excessive thirst or urination

Adrenal Gland Problems

Weight gain/ loss

Patient His­to­ry

Patient History