Weaverville Family Medicine
Medical History Form

PATIENT MEDICAL HISTORY - Patient Name:____________________________________ Date of Birth ____________

Past Medical History:
Medical: ___________________________________________________________________________________
Surgical: __________________________________________________________________________________
Childhood diseases: ________________________________________________________________________
Current Medications: _______________________________________________________________________
Allergies/Adverse Reactions: _______________________________________________________________
Last Tetanus Immunization: _________________________

Social History
Marital Status: Single ___ Married ___ Divorced since ___________ Widowed since ___________
Have you signed a living will? yes ___ no ___
Occupation: _______________________________________________

Tobacco Use:
cigarettes: _______ Packs per day _______ For how long _________ Quit _____
Smokeless tobacco: _______
Alcohol Use: How much? _______________________ How often: _________________________
Caffeine Use: How much? _______________________ How often: _________________________
Exercise: How much? _______________________ How often: _________________________

Family Medical History

Mother:
Living ________ Age _____ Health Problems _________________________________________________
Deceased __________ Age ______ Cause of Death ______________________________________________

Father:
Living ________ Age _____ Health Problems _________________________________________________
Deceased __________ Age ______ Cause of Death ______________________________________________

Sisters:
Living ________ Age _____ Health Problems _________________________________________________
Deceased __________ Age ______ Cause of Death ______________________________________________

Brothers:
Living ________ Age _____ Health Problems _________________________________________________
Deceased __________ Age ______ Cause of Death ______________________________________________

Daughters:
Living ________ Age _____ Health Problems _________________________________________________
Deceased __________ Age ______ Cause of Death ______________________________________________

Sons:
Living ________ Age _____ Health Problems _________________________________________________
Deceased __________ Age ______ Cause of Death ______________________________________________

Thank-you for completing the Weaverville New Patient Forms. We look forward to serving you. If you have any questions or would like to schedule an appointment, please call us at (828)645-3066.