Alpine Family Practice

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Available Forms

Patient Information Form Patient Medical History Form

Patient Medical History Form

This is a confidential record of your medical history and will be kept in your chart.

Last name, First Name and Date of Birth *

Have you ever personally had or suffer from any of the following:

Please add detail to above answers and add others that have not been mentioned.

Please add any medical history information not on the checklist or give further history on checked boxes.

Medications

Please list all medications, doses and how frequently they are taken. Include over-the-counter and herbal medications.

Drug Allergies

Please list any drug allergies.

Previous Surgeries

Please add previous surgeries and dates of the surgeries.

Hospitalizations

Please add previous hospitalizations.

Social History

Marital Ststus

How many children do you have?

Do you smoke cigarettes?

If yes, how many packs a day and for how many years?

Do you chew tobacco or snuff?

Do you use illegal drugs?

Do you drink alcoholic beverages and how much do you drink?

Do you travel outside of the United States?

Birth History for Children Under 18 years of Age

Infants Birth Weight

Was the patient

What type of delivery was performed?

Were there any complications?

Examples - Maternal Diabetes, abruption, significant blood loss, previa, hypertension, cerclage etc.

Is the child in daycare? If yes is it full time or part time?

Family History

Please list all first-degree relatives (Including parents, siblings and children) with the following illnesses

Heart Attack

Diabetes

Elevated Cholesterol

Cancer

Stroke

Hypertension

Other

Women Only

When was your last menstrual period?

Do you have normal periods every month?

Do you have heavy/light flow, severe cramping or irregular timing of your menses.

Do you have pain or bleeding after sexual intercourse?

How many times have you been pregnant?

Have you had miscarriages or abortions? How many times have you given birth and how many children do you have?

What is your method of birth control?

Date of last pap smear and have you ever had an abnormal PAP?

Date of last mammogram and have you ever had an abnormal mammogram?

Do you do self breast exams?

Review of Systems

Please check if you have or had any of these symptoms in the last 6 months

Other concerning symptoms

You have finished this form. Please send it into the portal below or print it out and bring it with you to your visit. Thank you very much.

* Required field