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Medical History Form
Patient Information
Patient Information
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Select a location
Columbia Woods Medical Group
Fairlawn Family Practice
Family Practice Associates
Family Practice Center of Wadsworth
Great Trail Family Practice
Hearthstone Family Practice
Internal Medicine Of Green
Internal Medicine West
Louisville Medical Center
Medina Primary Care
North Canton Family Physicians
Northampton Primary Care
Northeast Family Health Care
Ohio Family Practice
South Main Street Medical Center
Springfield Primary Care
Springside Internal Medicine
Stow-Hudson Primary Care
Twinsburg Primary Care
Last Name
(Required)
First Name
(Required)
Middle Initial
Date of Birth
(Required)
MM slash DD slash YYYY
Sex
(Required)
Male
Female
Transgender
Current Medications
Please list medication name, dosage and directions
Allergies
Personal Medical History
Tobacco User
(Required)
Current smoker
Former smoker
Nonsmoker
Uses tobacco in other forms
Exercise
Diet
Regular
Diabetic
Low salt
Low fat
Low cholesterol
Low carbohydrate
High protein
Vegan
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Lactose free
Other
Alcohol
(Required)
No
Yes
Past
Recreational Drug Use
(Required)
No
Yes
Past
Occupation – Job/Role
Personal Medical History
Anxiety
Asthma
Cancer
Cancer
Chronic Kidney Disease
Congestive Heart Failure (CHF)
COPD (Emphysema)
Depression
Diabetes
Heart Attack
High Cholesterol
Hypertension (High Blood Pressure)
Neuropathy
Stroke
Vascular Disease
Family History
Father
Mother
Sibling(s)
Healthy
Colon Cancer
Breast Cancer
Depression
Diabetes
Heart Attack
High Blood Pressure
Stroke
Unknown
Hospitalizations
Surgeries
Specialists
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
