EmailMeForm
Patient Medical History
Name
First
Last
Birth Date
MM
/
DD
/
YYYY
Age
Gender
Please select
Male
Female
Describe briefly your present symptoms:
Please list the names of other practitioners you have seen for this problem:
Psychiatric Hospitalizations (include where, when, & for what reason):
Have you ever had ECT?
Yes
No
Have you had psychotherapy?
Yes
No
CURRENT MEDICATIONS
Drug allergies:
Yes
No
To what?
Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:
Name of drug
1.
2.
3.
4.
5.
Dosage
1.
2.
3.
4.
5.
PAST MEDICAL HISTORY
Do you now or have you ever had:
Diabetes
Heart murmur
Crohn’s disease
High blood pressure
Pneumonia
Colitis
High cholesterol
Pulmonary embolism
Anemia
Hypothyroidism
Asthma
Jaundice
Goiter
Emphysema
Hepatitis
Cancer
Stroke
Stomach/Peptic ulcer
Leukemia
Epilepsy (seizures
Rheumatic fever
Psoriasis
Cataracts
Tuberculosis
Angina
Kidney disease
HIV/AIDS
Heart problems
Kidney stones
Other...
Please specify
PERSONAL HISTORY
Were there problems with your birth?
Yes
No
Please specify
Where were your born & raised?
What is your highest education?
High school
Some college
College graduate
Advanced degree
What is your marital status?
Never married
Married
Divorced
Separated
Widowed
Partnered/significant other
What is your current or past occupation?
Are you currently working?
Yes
No
Are you
Retired
Disabled
Laid off
Sick leave
Hours per week
Do you receive disability or SSI?
Yes
No
For what disability & how long?
FAMILY HISTORY
Please enter you family's medical history here
Living
Deceased
N/A
Father
Age
Health and Psychiatric history
Age at death
Cause of death
Living
Deceased
N/A
Mother
Age
Health and Psychiatric history
Age at death
Cause of death
Yes
No
Siblings
For Living
List their ages
List their Health and Psychiatric history
For Deceased
List their ages at death
List their causes of death
Yes
No
Children
For Living
List their ages
List their Health and Psychiatric history
For Deceased
List their ages at death
List their causes of death
SYSTEMS REVIEW
In the past month, have you had any of the following problems?
General
Recent weight gain
Recent weight loss
Fatigue
Weakness
Fever
Night sweats
Nervous System
Headaches
Dizziness
Fainting or loss of consciousness
Numbness or tingling
Memory loss
Muscle/Joints/Bones
Numbness
Joint pain
Muscle weakness
Joint swelling
Throat
Frequent sore throats
Hoarseness
Difficulty in swallowing
Pain in jaw
Stomach and intestines
Nausea
Heartburn
Stomach pain
Vomiting
Yellow jaundice
Increasing constipation
Persistent diarrhea
Blood in stools
Black stools
Eyes
Loss of hearing
Pain
Redness
Loss of vision
Double or blurred vision
Dryness
Ears
Ringing in ears
Loss of hearing
Blood
Anemia
Clots
Skin
Redness
Rash
Nodules/bumps
Hair loss
Color changes of hands or feet
Heart and Lungs
Chest pain
Palpitations
Shortness of breath
Fainting
Swollen legs or feet
Cough
Kidney/Urine/Bladder
Frequent or painful urination
Blood in urine
Women Only
Abnormal Pap smear
Irregular periods
Bleeding between periods
PMS
Psychiatric
Depression
Excessive worries
Difficulty falling asleep
Difficulty staying asleep
Difficulties with sexual arousal
Poor appetite
Food cravings
Frequent crying
Sensitivity
Thoughts of suicide / attempts
Stress
Irritability
Poor concentration
Racing thoughts
Hallucinations
Rapid speech
Guilty thoughts
Paranoia
Mood swings
Anxiety
Risky behavior
Other Problems
Women's Reproductive History
Age of first period
Number of Pregnancies
Number of Miscarriages
Number of Abortions
Have you reached menopause?
Yes
No
Do you have regular periods?
Yes
No
At what age?
Date of your last period
MM
/
DD
/
YYYY
