Medical History Form — Primary Health Clinics of Mississippi

Patient Identification

Full Legal Name (Last, First, Middle)

Date of Birth (MM/DD/YYYY)

Today's Date

Primary Care Provider (if transferring)

Reason for Today's Visit

Please describe your main concern or reason for establishing care

Past Medical History — Check All That Apply

Hypertension (High Blood Pressure) Yes No

Type 2 Diabetes Yes No

Type 1 Diabetes Yes No

High Cholesterol / Hyperlipidemia Yes No

Heart Disease / Coronary Artery Disease Yes No

Heart Attack (Myocardial Infarction) Yes No

Heart Failure / Congestive Heart Failure Yes No

Stroke / TIA (Mini-Stroke) Yes No

Asthma Yes No

COPD / Emphysema / Chronic Bronchitis Yes No

Sleep Apnea Yes No

Kidney Disease / Chronic Kidney Disease Yes No

Thyroid Disease (Hypo / Hyper) Yes No

Obesity / Overweight Yes No

Arthritis (Osteo / Rheumatoid) Yes No

Osteoporosis Yes No

Depression / Anxiety Yes No

Cancer (specify below) Yes No

HIV / AIDS Yes No

Hepatitis B or C Yes No

Anemia / Blood Disorder Yes No

Seizure Disorder / Epilepsy Yes No

Migraines / Chronic Headaches Yes No

Acid Reflux / GERD / Ulcers Yes No

Other conditions / additional details (including cancer type if applicable)

Surgical History

Surgery / Procedure	Year (approximate)	Hospital / Location

Current Medications (including vitamins & supplements)

Medication Name	Dose / Strength	Frequency	Reason / Condition

If you take more medications than space allows, please bring a complete medication list to your appointment.

Allergies

Known Drug Allergies?

Yes No NKDA

List all drug allergies and reactions

Other allergies (food, latex, environmental) and reactions

Family Medical History — Check All That Apply in Immediate Family

Heart Disease (early onset) Yes No Unknown

Hypertension Yes No Unknown

Diabetes (Type 1 or 2) Yes No Unknown

Stroke Yes No Unknown

Cancer (specify type below) Yes No Unknown

High Cholesterol Yes No Unknown

Kidney Disease Yes No Unknown

Mental Health Conditions Yes No Unknown

Thyroid Disease Yes No Unknown

Osteoporosis Yes No Unknown

Additional family history details (cancer type, age of onset, etc.)

Social History

Tobacco Use

Never Former (quit: ______) Current — packs/day: ______

Alcohol Use

None Occasional Moderate (1–2/day) Heavy (>2/day)

Recreational Drug Use

None Past Current — type: _______________

Exercise / Physical Activity

Sedentary Light (<2x/wk) Moderate (3–4x/wk) Active (5+/wk)

Diet Description

No restrictions Low sodium Diabetic Vegetarian / Vegan Other: _______________

Occupation / Work Environment

Current Symptoms — Check Any You Are Currently Experiencing

General

Fatigue Unintentional weight loss Unintentional weight gain Night sweats Fever / chills

Cardiovascular / Respiratory

Chest pain / pressure Shortness of breath Palpitations Leg swelling Chronic cough Wheezing

Gastrointestinal

Nausea / vomiting Abdominal pain Heartburn / reflux Diarrhea Constipation Blood in stool

Neurological / Mental Health

Headaches Dizziness Numbness / tingling Memory problems Depression Anxiety Sleep problems

Musculoskeletal / Skin

Joint pain / stiffness Back pain Muscle weakness Skin rash / lesions Hair loss

Urinary / Reproductive

Frequent urination Painful urination Blood in urine Urinary incontinence Erectile dysfunction Irregular periods

Please describe your most concerning current symptom(s) in more detail

Certification

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that withholding or providing inaccurate information may affect my medical care.

Patient / Guardian Signature

Date