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BSA New Patient Form: Medical History
Full Name
Date of Birth
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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Year
Year
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
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1940
1941
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1945
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1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Drug Allergies
Current Medications
Surgeries/Hospitalizations (please list the dates and procedure or diagnosis)
Past Medical Issues
Allergies
Anemia
Arthritis
Asthma
Bronchitis
Cancer
Chicken pox
Diabetes
Diphtheria
Ear Infection
Gout
Heart Murmur
Hepatitis/Jaundice
Herpes
High Blood Pressure
Kidney Stones
Measles
Mental Illness
Mumps
Osteoporosis
Pneumonia
Polio
Prostate Issues
Psoriasis
Rheumatic Fever
Rubella
Scarlett Fever
Stomach ulcers
Stroke
Thyroid Problems
Tuberculosis
Urine Infections
Venereal or Sexually Transmitted Infections
Pregnant
Yes
No
Planning
Not Applicable
Date of Last Period
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2021
2022
2023
2024
2025
Number of Pregnancies
Number of Abortions
Number of Miscarriages
Number of Live births
Birth Control Method
Date of Last Pap Smear
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date of Last Mammogram
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date of Last Tetanus Shot
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date of Last Flu Shot
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date of Last Pneumonia Shot
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date of Last Cholesterol Test
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date of Last Stool/Rectal Test
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date of Last TB Skin Test
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Do you drink alcohol?
Yes
No
Alcohol - How often and how much at a time?
Do you smoke?
Yes
No
How often and how long have you been smoking?
Do you use illegal drugs?
Yes
No
Illegal drugs - How often and how much at a time?
Family History
Alcoholism
Asthma
Cancer
Diabetes
Glaucoma
Heart Disease
High Blood Pressure
Kidney Disease
Mental Illness
Migraines
Osteoporosis
Seizures
Stroke
Thyroid Problems
Other
Current or Recent Symptoms
Black Stool
Bleeding
Diarrhea or Constipation
Dizziness
Ear Ringing
Fatigue
Feeling Nervous or Sad
Hair Loss
Headaches
Heartburn
Hemorrhoids
Hernia
Loss of Appetite
Memory Loss
Nausea or Vomiting
Pain
Rash/Itching
Vision Loss
Weight Loss
Other
If you selected Bleeding, please describe:
If you selected Pain, please describe:
If you selected Rash/itching, please describe:
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