37450 Dequindre Road, Sterling Heights, MI 48310

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586.979.5100

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Medical History

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Personal Information
Today's Date*
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First Name*
Middle Name*
Last Name*
Age*
Birth Date*
MM slash DD slash YYYY

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Sex*
- Male
- Female
Cell Phone Number*
e.g. (555) 555-5555
Work Phone Number
e.g. (555) 555-5555
Occupation*
Email Address*

e.g. email@domain.com
Emergency Contact Name*
Emergency Contact Phone Number*
e.g. (555) 555-5555
Marriage Status*
- Single
- Married
- Committed
- Divorced
- Widowed
- Separated
Spouse/Legal Partner’s Name
First Last
Allergies to Medications, X-Ray Dyes, or Other Substances*
- Yes
- No
Please list name of medicine or dye and type of reaction*

Medical History
Please check off if you have had any problems with or are presently experiencing any of the following:
- High Blood Pressure
- Diabetes
- Cancer
- Heart Disease
- Heart Attack
- Heart Failure
- Hepatitis B
- Hepatitis C
- Asthma
- Thyroid Disorder
- Depression
- Stroke
- Seizure Disorder
- Stomach Ulcers
- AIDS
- Bipolar Disorder
Type of Cancer

Gynecologic and Obstetric History
Age at onset of periods
Frequency
Length of period
Pregnancies
Births
Miscarriages
Have you experienced any of the following:
Prolonged or abnormal bleeding
- Yes
- No
Leakage of urine
- Yes
- No
Pelvic pain
- Yes
- No
Abnormal discharge
- Yes
- No
History of abnormal Pap smear
- Yes
- No
If Yes to any above, please describe:

Please List and Supply the Dates of:
Surgeries
Hospitalizations other than surgery
Immunization History
Hepatitis B Vaccination?*
- Yes
- No
When?*
Pneumonia Vacc 23/2013/20*
- Yes
- No
When?
Flu Vaccination?*
- Yes
- No
When?*
Tetanus Vaccination?*
- Yes
- No
When?*
Hepatitis A Vaccination?*
- Yes
- No
When?*
Zostavax/Shingrix (shingles)?*
- Yes
- No
When?*
Other?
- Yes
- No
When?*
When was your last:
Pap Smear?
MM slash DD slash YYYY

e.g. mm/dd/yyyy
Breast Exam?
MM slash DD slash YYYY

e.g. mm/dd/yyyy
Mammogram?
MM slash DD slash YYYY

e.g. mm/dd/yyyy
Sigmoidoscopy/Colonoscopy?
MM slash DD slash YYYY

e.g. mm/dd/yyyy
Cholesterol Check?
MM slash DD slash YYYY

e.g. mm/dd/yyyy
Prostate Exam?
MM slash DD slash YYYY

e.g. mm/dd/yyyy
PSA?
MM slash DD slash YYYY

e.g. mm/dd/yyyy
Eye Exam?
MM slash DD slash YYYY

e.g. mm/dd/yyyy
Dental Check-up?
MM slash DD slash YYYY

e.g. mm/dd/yyyy
Skin Cancer Screen?
MM slash DD slash YYYY

e.g. mm/dd/yyyy

Family History
Has any member of your family (including parents, grandparents, and siblings) ever had the following?
Cancer
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?
Hypertension (high blood pressure)*
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?
Hyperlipidemia (high cholesterol)*
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?
Heart Disease or unexplained sudden death
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?
Diabetes*
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?
Strokes*
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?
Mental disease (anxiety, depression, etc.)*
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?
Drug or alcohol addition*
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?
Bleeding diseases or blood clots*
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?
Other
- Yes
- No
Please describe illness:*
Which family members? Age when diagnosed?

Prevention and Social History
Do you wear seat belts?
- Yes
- No
If no, why not?*
Do you wear a bike helmet?
- Yes
- No
- N/A
Do you exercise regularly?
- Yes
- No
If yes, type, duration and number of times per week?*
Do you smoke?*
- Yes
- No
If yes, how many packs per day?*
Do you drink alcoholic beverages?*
- Yes
- No
If yes, how much per week?*
Do you drink coffee or tea?
- Yes
- No
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
- No
- N/A
Do you use street drugs? (marijuana, cocaine, etc.)
- Yes
- No
If yes, explain:*
Have you ever engaged in any activity which has put you at risk of getting AIDS?
- Yes
- No
If yes, explain:*
Have you ever worked with chemicals, paints, asbestos, or other hazardous materials?
- Yes
- No
If yes, explain:*
Are you or have you been in a relationship in which you were physically abused by your partner?
- Yes
- No
Do you have a “living will”?
- Yes
- No
Do you have a donor card?
- Yes
- No
Do you practice birth control?
- Yes
- No
If yes, method:*
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37450 Dequindre Road Sterling Heights, MI 48310

(586) 979-5100
frontdesk@tricountymedicalclinic.com

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