My Medical History at Evidence Medicine.com
When completed, print and take to ALL doctor visits, all emergency room visits,
all hospitalizations (especially surgeries - request this be placed on the front of your
chart) and when vacationing.  Keep multiple copies and repeatedly review for errors.
Evidence Medicine.com does NOT collect or store your personal history information.
Your Name:
Last Name      First Name:  
Middle Initial   Last 3 digits of SS#
Birthdate
Month: ----- January February March April May June July August September October November December Day     -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 23 24 25 26 27 28 29 30 31    Year: 19 20
My PCP (Primary Care Physician) Phone
My Cardiologist   Phone#
My Pharmacy    Phone#
My Primary Emergency Contact Phone
Check all conditions which you have or are being treated for
 Hypertension (High blood pressure; check yes even if controlled)  JNC 7 Hypertension Guidelines
 Diabetes  ADA 2007 Diabetes Guidelines  ADA 2008 Diabetes Guidelines
 High Cholesterol (check yes if on any cholesterol medications) Cholesterol Guidelines NCEP 2004
         LDL(bad chol)=    HDL(good)=
 Tobacco use (cigarettes, cigars or chew)     Currently smoke   Quit smoking
        EVERYONE should answer this regarding tobacco history
      ---- Never used only tried briefly Quit more than 10 years ago Quit beween 5-10 years ago Quit within last 1-5 years Quit within last 1-12 months Quit less than 1 month ago Never quit - I use tobacco
 Overweight      Obese   Height   -- 3 4 5 6 7 feet   -- 0 1 2 3 4 5 6 7 8 9 10 11 inches     (overweight / obese) range 4 ft 10 in (119 lb + / 143 lb +) 4 ft 11 in (124 lb + / 148lb+) 5 ft 0 in (128 lb + / 153 lb +) 5 ft 1 in (132 + / 158 lb +) 5 ft 2 in (136 + / 164 lb +) 5 ft 3 in (141 lb + /169 lb +) 5-4 (145 + / 174 +) 5-5 (150 + / 180 +) 5-6 (155 + / 186 +) 5-7 (159 + / 191 +) 5-8 (164 + / 197 +) 5-9 (169 + /203 +) 6-0 (184 + / 221 +) 6-2 (194 + / 233 +) 6-4 (205 + / 246 +)      
        Weight  lbs   kgs
 COPD or Emphysema         Asthma    Sleep Apnea
 Coronary Artery Disease
 Heart Attack (Myocardial Infarction)   Month: ----- January February March April May June July August September October November December    Year: 19 20
 Heart (Coronary) Angioplasty or Stent    Month: ----- January February March April May June July August September October November December    Year: 19 20
 Heart Bypass Surgery (CABG)   Year: 19 20
 Congestive Heart Failure LVEF (ejection fraction) =        %
 Atrial Fibrillation (A Fib) or Atrial Flutter        chronic (persistent)        paroxysmal (intermittent)
    ICIS 2004 Atrial Fibrillation Guidelines    ACC/AHA/ESC Atrial Fibrillation 2006 Summary
 Valvular heart disease    Mitral Valve Prolapse (MVP)         Mitral Regurgitation   
      Aortic Regurg.         Aortic Stenosis
 Stroke (CVA) or Mini-Stroke (TIA)
 Peripheral Arterial (Vascular) Disease
 Aneurysm - select type  Abdominal Aortic    Thoracic (chest) Aortic   Brain (cerebral)
 DVT (Deep Venous Thrombosis)   Pulmonary Embolism (PE)
 Kidney (Renal) Failure requiring Dialysis now         Renal Insufficiency (kidney weakness)
 Cancer. Check all that apply:        Lung       Breast      Colon       Prostate      Ovarian
OTHER MEDICAL CONDITIONS:
      Amer Cancer Soc Cancer Screening Guidelines (click for online access)
      For Men and Women:  My last colonscopy Year: 19 20 ;   last Flex Sigmoid Year: 19 20
      last check for blood in stool (FOBT or FIT)  Year: 19 20 ; Barium Enema  Year: 19 20
   I am over 50 and NEVER had any screening test for COLON CANCER
      For WOMEN:  Last Mammogram  Year: 19 20 ;   Last PAP/Pelvic exam  Year: 19 20
      I am over 40 and NEVER had a MAMMOGRAM for BREAST CANCER screening
 Gastrointestinal (GI - stomach, esophagus, colon) Bleeding
 Peptic (stomach) Ulcer Disease
 Anemia           Blood transfusion history   I have had a blood transfusion    Year: 19 20
 Pacemaker   Manufacturer:  ---- Guidant Medtronic St. Jude Other Not sure
 Defibrillator (ICD)  Manufacturer:  ---- Guidant Medtronic St. Jude Other Not sure
 Pacemaker with Defibrillator  Manufacturer:  ---- Guidant Medtronic St. Jude Other Not sure
 BiVentricular Pacemaker   Manufacturer:  ---- Guidant Medtronic St. Jude Other Not sure
 Aortic Valve Replacement
 Mitral Valve Replacement
 Mitral Valve Repair
OTHER SURGERIES:
Last Name        First Name:  
MAKE SURE YOU FILL IN YOUR NAME AGAIN IN SPACES ABOVE.
User agrees that EvidenceMedicine.com and its operators cannot be held responsible
in any way for errors or omissions on this medical history.  All medical histories:
verbal, written, electronic or other are prone to errors.  All users (patients and
medical professionals) should always suspect the possibility of inaccuracies in
any form of medical history and should  repeatedly check for errors.
(c) EvidenceMedicine.com 2007

  This form was completed by me (the patient) alone.
  This form was completed by me with help from:
        My husband  My wife   My daughter    My son    My mother    My father
      A friend     A nurse    A doctor    Someone else
  This form was completed by: