Medical History Form

To help you prepare for your first appointment with your healthcare provider, we have provided this sample medical history form adapted from Managing and Treating Urinary Incontinence by Diane Kaschak Newman. You may complete it online and print your answers or you may print a blank copy and fill in your answers by hand later. To protect your privacy, NAFC is not capturing any personal identities relating to medical history, therefore it will not be possible for you to recover this form or edit it after closing. If you have questions regarding any of the terms on this form, please refer to our online glossary for assistance.

Please fill out and print the following medical history form. This form is intended to help you and your doctor at the time of your appointment.


 
Name Date
Gender Male Female Age
1. Education:
 
Less than high school
Completed high school
More than high school
2. Occupation (now or last job):
 
3. Date of last complete medical exam:
 
Within last month
Within last 6 months
More than 6 months
4. Allergies (medications, foods, or other):
 
Substance Allergic To Reaction
5. Do you drink alcohol?
 
Yes No
If yes, indicate number of glasses per week:
Beer (glasses)
Wine (glasses)
Spirits (ounces)
6. Indicate what amount you drink of the following in a typical day
 
Water (8 oz. glasses)
Juice (8 oz. glasses)
Coffee (cups)
Tea (cups)
Soda (8 oz. glasses)
7. Have you ever been diagnosed or treated for cancer, a tumor, or noticed any lumps or swelling?
 
Yes No
Please describe:
8. Have you ever been treated for any of the following:
 
  Yes No
Anxiety
Depression
Nervous problems
Alcoholism
Drug addiction
9. Do you have trouble with:
 
  Yes No
Feeling of tingling or numbness
in any parts of your body
Weakness in your arms and legs
Weakness in one side of your body
10. Please select the appropriate option if you use any of the following:
 
Cane Wheelchair Walker
11. Do you smoke?
 
Yes No
If yes, how many every day?:
Cigarettes
Cigars
Pipe
Chew tobacco
Recreational drugs
12. List all medications you are currently taking (prescription and over-the-counter):
 
Name, Dosage and Reason for Taking
13. Which, if any, of the following have you been treated for?
 
Alzheimer's disease/dementia Falls Osteoporosis
Anemia Fractures/joint replacements Pacemaker
Arthritis Glaucoma Parkinson's disease
Asthma Head injuries Polyps
Back injuries/back compression fractures Heart disease (CAD, arrhythmia, atrial fibrillation) Renal disease
Bleeding problems Heart attack Seizures
Cancer Heart murmurs Skin sensitivities or conditions
Cataracts Hemorrhoids Stroke
Chest pain High blood pressure Vascular disease/PVD
Congestive heart failure Irritable bowel    
Constipation/impaction Kidney stones/bladder stones    
COPD Mitral valve prolapse    
Diabetes Multiple Sclerosis    
  Other-specify        
 
Urological Review - Both Men and Women
14. Prior Genitourinary history:
 
Hysterectomy yr. Bladder tumor
 
Vaginal
Abdominal
Ovaries removed
Bladder surgery
Pelvic radiation
Prostatitis/BPH
Urethral stricture/dilatation Prostate Cancer
Discharge - genital area Collagen infections
Urinary tract infection
 
Date:
Type:
  Other-specify
 
Gynecological Review - Women Only
15. Gynecological review
 
Prolapse
Bladder Uterus
Rectum    
Menstrual cycle information
Date of last period
Date of last pap smear
Pregnancy and childbirth information
Use of:
Pessary IUD Diaphragm
Birth Control
  Specify
# of Pregnancies
# of Vaginal deliveries
# of Cesarean sections
# of Episiotomies
Previous surgery:
 
    
Updated: Dec.05.2007