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Use the opposite side of the page as necessary to complete your answers. Please print legibly.
Name ______________________________________________________________________________________ Address ____________________________________________________________________________________ Phone (w) __________________________ (h) _________________________ (c) _________________________ DOB __________________________ Age ______________SS# ______________________________________ Emergency Contact ___________________________________________________________________________ Relationship to patient _________________________________ Phone __________________________________ Primary care physician _________________________________ Phone _________________________________ Date of last physical __________________ Have you ever had an EKG? ( ) N Date _____________________ Current or past medical conditions (check all that apply) ( ) Cardiovascular (heart attack, high cholesterol, angina) Other (Please describe) ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ If there a family history of any of the illnesses listed above, please put an “F” next to that illness MD NOTES __________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Is there a family history of anything NOT listed here? (Please explain) __________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ MD NOTES ________________________________________________________________________________ ___________________________________________________________________________________________ Have you ever had surgery or been hospitalized? (Please describe) ____________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ MD NOTES ________________________________________________________________________________ ___________________________________________________________________________________________ Have you or a family member ever been diagnosed with a psychiatric or mental illness? (Please describe) ___________________________________________________________________________________________ Have you ever taken or been prescribed antidepressants? ( ) N For what reason ________________________ Medication(s) and dates of use ______________________________ Why stopped ________________________ Please list all current prescription medications and how often you take them (example: Dilantin 3x/day). DO NOT include medications you may be currently misusing (that information is needed later) ______________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Please list all current herbal medicines, vitamin supplements, etc. and how often you take them ___________________________________________________________________________________________ MD NOTES ________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Please list any allergies you have (penicillin, bees, peanuts) _____________________________________________________________________________________ MD NOTES _________________________________________________________________________ Have you ever been treated for substance misuse? ( ) N (Please describe when, where and for how long) ________________________________________________________________________________ How long have you been using substances? Did you ever stop using any of the above because of dependence? ( ) N (Please list) _____________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ What was your longest period of abstinence? ______________________________________________________ ___________________________________________________________________________________________ MD NOTES ________________________________________________________________________________ ___________________________________________________________________________________________
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Source: http://www.drkares.us/Documents/Mediical_HistoryTHP.pdf