Medical History & Physical History - Fox Valley Pulmonary Medicine

Patient Name*

First Last

Date of Birth*

Today's Date*

Would you like to discuss anything with the doctor?

Who is your primary doctor?*

Reason for visit?

Patient Profile

Select Marital Status*

Single
Married
Separated
Divorced
Widowed

Last School Grade completed*

Occupation*

Occupation - are you retired?*

Yes
No

Hobbies/Interests*

Date of your last complete medical exam

Health of Family

Please select the health of your family members below.

Father (natural, biological)

Good
Poor
Died

If your Father is deceased, note age & cause of death. Include fatal accidents and suicides.

Mother (natural, biological)

Good
Poor
Died

If your Mother is deceased, note age & cause of death. Include fatal accidents and suicides.

Mother (natural, biological)

Good
Poor
Died

If your Mother is deceased, note age & cause of death. Include fatal accidents and suicides.

Brother 1

Good
Poor
Died

If your Brother is deceased, note age & cause of death. Include fatal accidents and suicides.

Brother 2

Good
Poor
Died

If your Brother is deceased, note age & cause of death. Include fatal accidents and suicides.

Brother 3

Good
Poor
Died

If your Brother is deceased, note age & cause of death. Include fatal accidents and suicides.

Sister 1

Good
Poor
Died

If your Sister is deceased, note age & cause of death. Include fatal accidents and suicides.

Sister 2

Good
Poor
Died

If your Sister is deceased, note age & cause of death. Include fatal accidents and suicides.

Sister 3

Good
Poor
Died

If your Sister is deceased, note age & cause of death. Include fatal accidents and suicides.

List any other Brother(s) or Sister(s) - please include their Health: Good, Poor or Died.

(if deceased, note age & cause of death. Include fatal accidents and suicides)

Spouse

Good
Poor
Died

If your Spouse is deceased, note age & cause of death. Include fatal accidents and suicides.

Child 1

Good
Poor
Died

If your Child is deceased, note age & cause of death. Include fatal accidents and suicides.

Child 2

Good
Poor
Died

If your Child is deceased, note age & cause of death. Include fatal accidents and suicides.

Child 3

Good
Poor
Died

If your Child is deceased, note age & cause of death. Include fatal accidents and suicides.

Child 4

Good
Poor
Died

If your Child is deceased, note age & cause of death. Include fatal accidents and suicides.

List any other Children - please include their Health: Good, Poor or Died.

(if deceased, note age & cause of death. Include fatal accidents and suicides)

Immunizations - Check those you have received.

Select All
FLU
TETANUS
RUBELLA
PNEUMONIA
TB SKIN TEST

Please specify the Year you received the selected Immunizations

Social History

Do you presently smoke?*

Yes
No

If yes, how many years have you smoked?

How much do you smoke per day?

If you are an ex-smoker, how many years did you smoke?

How much did you smoke per day?

Have you traveled out of the area in the last year?*

Yes
No

If yes, what Area(s) have you traveled too?

Do you have pets?*

Yes
No

If yes, what kind of pets do you have?

Have you ever had birds?*

Yes
No

Illnesses

Check all Illnesses you have had:

Check all Illnesses any Blood Relative has had:

Hospitalizations / Surgeries

List what the illness was, what kind of operation and the year it occurred. Exclude normal pregnancies.

Medications

List all medications, birth control pills vitamins and/or herbal/natural supplements you take with or without prescription. Include strength if known.

Are you allergic to any medications?*

Yes
No

If yes, please list the medications you are allergic to.

Do you have other allergies?*

Yes
No

If Yes, please indicate the type of allergies

Have you ever had skin testing?*

Yes
No

What year did you have the testing preformed?

Do you use home oxygen?*

Yes
No

Any Comments or Questions

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