Past Medical History

Medications
Generic/Brand Dosage Route Frequency Purpose

• Home remedies
• Nonprescription drugs
• Vitamins
• Mineral supplement
• Herbal supplement
• Oral contraceptives

Immunizations
• BCG
• Hepa B
• Rotavirus
• DPT
• Hib
• Pneumococcal
• Polio
• Influenza
• MMR
• Varicella
• Hepa A
• HPV
• Meningococcal

Allergies
Food:
Medications:
Pollen:
Animals:
Environmental factors:

Childhood Illness
• Rheumatic fever
• Scarlet fever
• Chicken pox
• Mumps
• Measles
• Rubella
• Whooping cough
• Polio
Adult Illness
Illness Age Date of Diagnosis
Hypertension
Stroke
Renal
Asthma
TB
DM
Cardiac
GI
STD
Psychiatric
Others

Surgical Procedures
Date:
Type of operation:
Purpose:

Previous Hospitalizations
Date Cause Hospital Treatment

Screening Tests
Test Date Result
Tuberculin test
Pap smear
Mammogram
Occult blood
Cholesterol test
Urinalysis
X-ray/CT scan/MRI
Others
Family History
Age Health/Diseases Age & date of Dx Cause of death
Father

Mother
Others

Medical Problems of Any Blood-Relative

Relationship to patient Age & date of diagnosis
Cancer
Hypertension
Diabetes
Tuberculosis
Heart disease
Stroke
Kidney disease
Thyroid disease
Arthritis
Blood disorder
Asthma
Lung disease
Epilepsy
Mental disorder
Suicide
Substance abuse
Genetically transmitted diseases
Others

Personal and Social History

Home situation:
Significant others:
Number of years married:
Health status of spouse:
Number of children:
Health status of children:
Source of stress:
Highest educational attainment:
Occupation:
Job history:
Financial situation:
Occupational hazards:
Smoking habits
• Non-smoker
 • Smoker
• Previous smoker
Number of sticks/packs per day:
Year started:
Year quitted:
Alcohol consumption
• Never
• Daily
• Occasionally
• Weekly
Alcohol type:
Amount consumed:
Nutrition:
Number of meals per day:
Usual daily food intake:
Food preferences:
Coffee/tea/soda intake:
Nutrient supplement:
OTC:
Prohibited drugs:
Substance abuse:
Frequency of exercise:
Regularity of sleep:
Activities of daily living
Habits/hobbies:
Leisure activities:
Religious affiliations:
Living conditions:
No. of years in current residence:
Previous place of residence:
Type of residence:
No. of rooms:
No. of occupants:
Relationship to occupants:
Source of drinking water:
Garbage disposal:
Fecal disposal:
Pet/s:
General state of neighborhood:

Menstrual and Obstetric History:

LMP: ____________ PMP: _______________
Age of menarche: ____________ Period: regular/irregular
Character of flow: ____________
Duration of period (range): ____________
No. of pads used per day: ____________
PMS: ___________________________________________________
Age of Menopause: _______

Gravidity: ______ Parity: _______

OB Index: ________ Term
________ Preterm
 ________ Abortions/Miscarriages
________ Living Children
Date of Birth Sex Manner of Delivery
______________________ ____________________
______________________ ____________________
______________________ ____________________

OB Hx: G _ P_ (T-P-A-L)
G1: When _________, NSD or CS d/t _________, delivered by _________, where _________, M/F, weight
_________, fetomaternal complications _____________________, present status __________.