MEDICAL HISTORY FORM Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * Work Number Fax Email Address Occupation Preferred Contact Method Home Phone Work Phone Mobile Email Name of Emergency contact * First Name Last Name Relationship with Emergency Contact * Emergency Contact Number * Name of Preferred Pharmacy * Phone * (###) ### #### Zip * Referred By Patient History * Diseases or Conditions (e.g., AIDS/HIV, Cancer, Diabetes, Heart Disease, etc.) Select all that apply * Allergies Heart Disease Diabetes Neurological Disorders Allergy * List any allergies and reactions Medications * List all current medications Are you under the care of a physician? Yes No Physician's Name Physician's Contact Clinic Name * Clinic Address List Surgeries/Conditions requiring hospitalization/Injuries Do you currently consume alcohol? Yes No If yes, how much/how often? Do you consume caffeine (e.g., coffee, tea, energy drinks)? Yes No If yes, how much/how often? Do you smoke cigarettes or use tobacco products? Yes No If yes, how many per day? Do you use recreational or non-prescribed drugs? Yes No If yes, please specify Have you used any of the above in the past but no longer do? Yes No If yes, specify which ones and when you quit List any family members with medical issues (e.g., mother, father, siblings) Details of medical problems or causes of death Men’s Health (for male patients only) Please check all that apply and provide additional details if needed. Issues with sexual function (e.g., erectile dysfunction, low libido) Prostate problems (e.g., enlarged prostate, pain, history of cancer) Penile discharge or genital symptoms Are you currently sexually active? Yes No Women’s Health (for female patients only) Please check all that apply and provide additional information where indicated. Irregular or painful menstrual cycles Abnormal Pap smear results Breast lumps or concerns Date of last menstrual period (LMP): Date of last Pap smear: Date of last mammogram: Are you currently using any form of birth control? Yes No Obstetric History (for female patients only) Please complete the following: Total number of pregnancies: Number of live births: Number of miscarriages: Number of C-sections: Any complications during pregnancy, labor, or delivery? Yes No Signature and Date Confirm all information is correct and that the patient agrees to the clinic’s terms Sign here Thank you!