FORM: Medical History - Inspire Medical Group

Personal Information

Date*

Month

Day

Year

Name*

First Last

Date of Birth*

Month

Day

Year

Age*

Sex*

Status*

Spouse's Name*

First Last

Race*

Ethnicity*

Language*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Work Phone*

Children’s names and ages

Allergies

Allergies to Medications, X-Ray Dyes, or Other Substances?

Yes

If Yes, please list name of medicine and type of reaction

Medications (Prescriptions, Over-the-Counter, Vitamins, Herbs etc.)

Past Medical History and Review of Systems

Please check if you have had any problems with or are presently experiencing any of the following:

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High Blood Pressure

Diabetes

Heart disease

Chest pain/tightness

Shortness of breath

Swollen ankles

Palpitations

Lightheadedness

Frequent urination

Rheumatic fever

Asthma

Bronchitis

Pneumonia

Persistent cough

Tuberculosis

Hay Fever

Headache

Thyroid Disease

Indigestion

Nausea

Vomiting

Constipation

Diarrhea

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Change in Bowel Habits

Unexplained weight gain/loss

Hemorrhoids

Gall bladder disease

Colitis

Hepatitis or Jaundice

Anxiety

Head or neck radiation

Abdominal discomfort

Kidney disease

Kidney stones

Impotence or Erectile Dysfunction

Arthritis

Low back problems

Difficulty Urinating

Skin diseases

Blood disorders

Venereal diseases

Depression

Anemia

Alcohol abuse

Drug abuse

Gout

Other

Gynecologic and Obstetric History

Age at onset of periods

Frequency

Length of Period

Pregnancies

Births

Miscarriages

Prolonged or abnormal bleeding

Yes

If yes, please describe

Leakage of Urine

Yes

If yes, please describe

Pelvic Pain

Yes

If yes, please describe

Abnormal discharge

Yes

If yes, please describe

History of abnormal Pap smear

Yes

If yes, please describe

Hospitalizations

Please list and supply the dates of operations

Please list and supply the dates of hospitalization other than for surgery

Immunization History

Have you had Hepatitis B?

Yes

Have you had Flu?

Yes

Have you had Pneumovax?

Yes

Have you had Tetanus?

Yes

Have you had other?

Yes

If Yes, please describe

When was your last Pap Smear?

Month

Day

Year

Leave blank if Not Applicable

When was your last Breast Exam?

Month

Day

Year

Leave blank if Not Applicable

When was your last Colon Cancer Test?

Month

Day

Year

Leave blank if Not Applicable

When was your last Mammogram?

Month

Day

Year

Leave blank if Not Applicable

When was your last Cholesterol check?

Month

Day

Year

Leave blank if Not Applicable

When was your last Prostate Exam?

Month

Day

Year

Leave blank if Not Applicable

Family History

Father

Age, Sate of Health, Age at Death (if applicable), Cause of Death (if applicable)

Mother

Age, Sate of Health, Age at Death (if applicable), Cause of Death (if applicable)

Brothers

Age, Sate of Health, Age at Death (if applicable), Cause of Death (if applicable)

Sisters

Age, Sate of Health, Age at Death (if applicable), Cause of Death (if applicable)

Check if your blood relatives had any of the following:

Arthritis, Gout

Asthma, Hay Fever

Cancer

Chemical Dependency

Diabetes

Heart Disease, Stroke

High Blood Disease

Tuberculosis

Other

Relationship to you (relative who has/had Arthritis, Gout)

Relationship to you (relative who has/had Asthma, Hay Fever)

Relationship to you (relative who has/had Cancer)

Relationship to you (relative who has/had Chemical Dependency)

Relationship to you (relative who has/had Diabetes)

Relationship to you (relative who has/had Heart Disease, Stroke)

Relationship to you (relative who has/had High Blood Disease)

Relationship to you (relative who has/had Tuberculosis)

Relationship to you (relative who has/had Other - please describe)

Prevention

Do you wear seat belts?

Yes

If no, why not?

Do you wear a bike helmet?

Yes

N/A

Do you exercise regularly?

Yes

If yes, duration and number of times per week

Do you smoke?

Yes

If yes, how many packs per day?

Do you drink alcoholic beverages?

Yes

If yes, how much per week?

Do you drink coffee?

Yes

If yes, how many cups per day?

Do you drink tea?

Yes

If yes, how many cups per day?

If there is a gun in your home, do you keep it unloaded and out of children’s reach?

Yes

N/A

Do you use drugs (marijuana, cocaine, etc)?

Yes

If yes, explain:

Have you ever engaged in any activity that has put you at risk of getting AIDS?

Yes

If yes, explain:

Do you wish to be tested for AIDS?

Yes

If yes, explain:

Have you ever worked with chemicals, paints, asbestos or other hazardous material?

Yes

If yes, explain:

Are you in a relationship in which you have been physically hurt (e.g. slapped, kicked, punched, bruised) by your partner?

Yes

Do you ever feel afraid of your partner?

Yes

N/A

Do you have a ‘living will’?

Yes

Do you have a donor card?

Yes

Are you currently using a method of birth control?

Yes

If yes, what method?

Medical History

Personal Information

Allergies

Past Medical History and Review of Systems

Gynecologic and Obstetric History

Hospitalizations

Immunization History

Family History

Prevention

CONTACT

SERVICES