PRIMARY CARE Medical Group

Phone and Fax: (480) 459-4422 info@pcmgaz.com

Initials __________

Patient Medical History Form

ALLERGIES: _________________________________________________________________________________________ List ALL MEDICATIONS you take, including over-the-counter (OTC) medications and vitamins. Include specific doses and how/when taken. If you do not know, please call your pharmacist to confirm. (example: Aspirin 81mg 1 tab every morning) PERSONAL MEDICAL HISTORY:

Cardiovascular Ophthalmology Oxygen Use

Hypertension Glaucoma Chronic Bronchitis/Cough

Coronary Artery Disease Macular Degeneration Sleep Apnea

Past Heart Attack Glasses Use Pulmonary Embolism

Arrhythmia

Neurological/Mental Health

Edema (swelling) Alzheimer’s Dementia Rheumatoid Arthritis

Peripheral Artery Disease Age Related Dementia Osteoarthritis (generalized arthritis)

Stroke(side affected:☐Rt ☐Lt) Depression Back Pain

DVT (blood clot) Anxiety Chronic Generalized Pain

Agitation Problems Allergies, Seasonal

Gastrointestinal/Urological Parkinson’s Disease Anemia

Seizures Diabetes: type ☐ 1 ☐ 2

Diarrhea Neuropathy Hyperthyroidism

Irritable Bowel Syndrome ALS Hypothyroidism

Past GI Bleed MS Lupus

Diverticulosis Profound Weakness/Bed Bound HIV

Ulcerative Colitis Alcoholism Osteopenia/Osteoporosis

Crohn’s Disease Insomnia Cancer: Type ________________

GERD (Acid Reflux) Hearing Aides

Hernia Pulmonary All others not listed:

Hepatitis: Type ___ COPD

Urinary Incontinence Emphysema

Frequent Urinary Tract Infections Asthma

DATE: _______________ NAME: _______________________________________ DOB: _______________ GENDER:

Liver Disease Tobacco Use: Past Present

High Cholester Other

Constipation

1 of 2

PRIMARY CARE Medical Group

Phone and Fax: (480) 459-4422 info@pcmgaz.com

Initials __________

Test Done Year Results Would you like to continue these tests?

Colonoscopy

Dexa (Bone)

Mammogram

Pap

SURGICAL HISTORY: Please list all prior surgeries and approximate dates performed. SOCIAL HISTORY:

Education Level: ☐ Elementary ☐ High School ☐ Vocational ☐ College ☐ Graduate / Professional Previous Career: Hobbies:

Are there any vision problems that affect your activities of daily living? ☐Yes ☐ No

Are there any hearing problems that affect your communication? ☐Yes ☐ No

Current Living Situation: ☐ Private Home ☐ Assisted Living Facility/Home ☐ Skilled Nursing Facility ☐ Other: _________

Smoking/ Tobacco Use: ☐ Current ☐ Past ☐ Never Type: ______________ Amount/day: _____ Number of Years: _____

Alcohol: ☐ Current ☐ Past ☐ Never Drinks/week: __________ Type: ☐ wine ☐ beer ☐ liquor

Recreational Drug Use: ☐ Current ☐ Past ☐ Never Type: ____________________________________________________

Are you sexually active? ☐Yes ☐ No FAMILY HISTORY:

Mother: ☐Living ☐Deceased, due to___________ at Age ____. Significant medical history: _________________________

Father: ☐Living ☐Deceased, due to___________ at Age ____. Significant medical history: _________________________

Sibling: ☐Living ☐Deceased, due to___________ at Age ____. Significant medical history: _________________________

Sibling: ☐Living ☐Deceased, due to___________ at Age ____. Significant medical history: _________________________ I have read and agree with the above information and it is accurate to the best of my knowledge.

_____________________________________________________________________________ ___________________________ (Patient Signature) (Date) _____________________________________________________________________________ ___________________________ (Power of Attorney/Legal Guardian Signature) (Date)

2 of 2