Comprehensive Family Medicine Health History Form

Personal Information

• Full Name: _________________________ Date: __________
• Date of Birth: __________ Age: ____ Gender: ________
• Address: ____________________________________________
• Phone: ______________ Email: ________________________

Current Health Status

Present Health Concerns

1. Primary concern: _________________________________
2. Other concerns: __________________________________

Current Medications

Medical History

Chronic Conditions (check all that apply)

• Hypertension
• Diabetes
• Heart Disease
• Asthma/COPD
• Arthritis
• Cancer (type): _________
• Other: ___________

Surgical History

Family History

Social History

• Occupation: _______________
• Marital Status: ___________
• Exercise Frequency: _______
• Tobacco Use: [ ]Never [ ]Former [ ]Current
• Alcohol Use: [ ]Never [ ]Occasional [ ]Regular

Preventive Care

Last Physical Exam: __________ Last Flu Shot: ______________ Last Tetanus: ______________

Authorization

I certify that the above information is accurate to the best of my knowledge.

Signature: _______________ Date: ___________