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Past Medical History
ENT Hx
• • •
Other
Eye Hx
• • •
Other
Cardiovascular Hx
• • •
Other
Circulatory System
• • •
Other
Genitourinary
• • •
Other
Neurologic
• • •
Other
Endocrine & Metabolic
• • •
Other
Hematology
• • •
Other
Psychiatry
• • •
Other
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Gastrointestinal
• • •
Other
Pulmonology
• • •
Other
Musculoskeletal
• • •
Other
Skin
• • •
Other
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Additional Info
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Origin
Infectious Diseases
History of STD
History of STD (Add Info)
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Other Medical Problems
Other 1
Other 2
Other 3
Other 4
Social History
Highest Level of Education
Occupation
Military Service
Marital Status
Living Arrangements
Lives with (other)
Alcohol Consumption
Current Status
Sober Since
Type
• • •
Frequency
Drinks/day
/
Drinks/week
/
History of Tobacco Use
Status
Cigarettes, PPD
Date started
Date Quit
Fx Cigar Smoking
Fx Chew Tobacco
Recreational Drugs
Drugs/Details
Surgical History
Surgery
• • •
Date
1. Surgery
Date
2. Surgery
Date
3. Surgery
Date
Hospitalization History
1. Hospitalization
Date
2. Hospitalization
Date
3. Hospitalization
Date
4. Hospitalization
Date
5. Hospitalization
Date
Family History
Unknown reason
Father
• • •
Other history of Father
Mother
• • •
Other history of Mother
Brother
• • •
Other history of Brother
Sister
• • •
Other history of Sister
Other relative
• • •
Other history of relatives
Comments:
Womens Health History
Female Health History
• • •
Other
Menstrual History
Age of first period (years)
Frequency of period (days)
Duration of period (days)
Post Menopausal (years)
• • •
Pregnancy History
Total # of pregnancies
NSVD
C-Sections
Miscarriages
Abortions
Birth Control Method
• • •
Other Method
Month/Year
Infant Sex
• • •
Birth Weight
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Type of Delivery
• • •
Anesthesia
• • •
Comments/Complications

H&P Med / Fam / Social History Medical Form

Internist

Comprehensive Med/Fam/Soc History for IM

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Published: March 28, 2017, 6:59 p.m.
Doctor: Dr. History Physical
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