Tricity Family Medicine & Urgent Care Clinic, PLLC
107 Hyannis Dr., Holly Spring, NC 27540
Ph: 919-363-8666 Fax: 919-363-8668
1106 Parkside Main Street, Cary NC 27519
PH: 919-261-6446 Fax: 919-261-6448
MEDICAL HISTORY FORM
Patient's Name
Birth date : (MM/DD/YYYY)
Today date : (MM/DD/YYYY)
Do you smoke ? (yes/no)
SELECT
YES
NO
Packs per day
# Years smoked
Drink Alcohol?
Drinks per day
List any allergies you have to drugs, food or other items :
Are you currently under medical care for any reasons? If yes, please explain :
Past Psychiatric/Mental Health Care
Therapist’s Name :
For How Long and When :
Have you had any of the following surgeries performed ?
OTHER
TONSILS
APPENDIX
GALABLADDER
Other Operations Performed
Year
Hospital
Doctor
Please check if any relative (parents, siblings, grandparents, children) have had any of the conditions listed below :
Heart Disease
Kidney Disease
Asthma
Stroke
Bleeding Tendencies
Hypertension
Cancer
Seizures
Mental Illness
Emphysema/COPD
High blood pressure
Diabetes
Thyroid Disease
High Cholesterol
Other Serious Illness :
HEALTH MAINTENANCE: Please list the year of your last screening test below. Please indicate there were any abnormal result.
Physical Exam
Pap Smear
Memogram
Colonoscopy
Cholesterol Test
Prostate Exam
Blood work / LABS
Eye Exam
Bone Density Check
HEALTH MAINTENANCE: Immunization / Vaccine: Please list the year of your last shot below.
Tetanus Shot
Hepatitis A
Hepatitis B
Chicken Pox
Pneumonia Shot
MMR
TB Skin Test
Flu Shot / Flu Mist
Signature of responsible party
Date