Medical History Report

---

Patient Information

• Name: [Patient's Name]

• Date of Birth: [Patient's Birthdate]

• Gender: Male

• Address: [Patient's Address]

• Phone Number: [Patient's Contact Number]

• Email: [Patient's Email]

---

1. Medical History

1. Past Medical History:

   • Hypertension: Diagnosed in March 2060; patient currently manages this condition through lifestyle modifications and medication.

   • Appendectomy: Underwent surgery in April 2060 due to acute appendicitis; no complications noted post-surgery.

   • Seasonal Allergies: Diagnosed in May 2060 with symptoms exacerbated during spring and fall; managed with over-the-counter antihistamines.

2. Current Medications:

   • Lisinopril: 10 mg, taken once daily for hypertension management.

   • Cetirizine: 10 mg, taken as needed for allergy symptoms.

   • Aspirin: 81 mg, taken once daily as a preventive measure for cardiovascular health.

   • Multivitamin: Daily supplement for general health maintenance.

3. Allergies:

   • Penicillin: Experienced rash upon administration.

   • Latex: Reports itching and redness upon contact.

   • No known food allergies.

---

2. Family History

1. Father:

   • Heart disease diagnosed in 2060; passed away in 2060 from a heart attack.

2. Mother:

   • Diagnosed with type 2 diabetes in 2060; currently managing with medication and lifestyle changes.

3. Siblings:

   • Sister: Asthma diagnosed in 2060; uses an inhaler as needed.

   • Brother: No significant medical history; active and healthy.

---

3. Social History

1. Occupation:

   • Software Developer at Tech Innovations Inc. since 2060.

2. Lifestyle Factors:

   • Tobacco Use: No history of tobacco use.

   • Alcohol Use: Consumes alcohol occasionally, approximately 1-2 drinks per week.

   • Illicit Drug Use: Denies any use of illicit drugs.

   • Physical Activity Level: Engages in regular exercise 4-5 times per week, including jogging (30 minutes) and cycling (1 hour).

---

4. Review of Systems

1. General:

   • No recent weight changes; reports occasional fatigue but attributes it to work stress.

2. Cardiovascular:

   • Denies chest pain; reports mild palpitations during strenuous exercise.

3. Respiratory:

   • Experiences occasional cough during allergy season; no reports of shortness of breath or wheezing.

4. Gastrointestinal:

   • Experiences occasional heartburn, particularly after large meals; no reports of nausea or vomiting.

5. Genitourinary:

   • No changes in urination patterns; denies any discomfort or pain.

6. Musculoskeletal:

   • Reports occasional joint pain in knees after prolonged running; no swelling or redness noted.

7. Neurological:

   • Experiences occasional headaches, especially during stressful periods; no episodes of dizziness or fainting.

8. Psychiatric:

   • Reports mild anxiety related to work pressures but no depressive symptoms; manages anxiety through relaxation techniques and exercise.

---

5. Immunization History

• Influenza Vaccine: Received annually since 2060; last administered in October 2060.

• Tetanus-Diphtheria: Last received in March 2060; due for a booster in March 2070.

• COVID-19 Vaccination: Completed full vaccination series in March 2060; received booster in November 2060.

• Shingles Vaccine: Administered in June 2060; no adverse effects.

---

6. Additional Notes

1. Recent laboratory tests conducted in September 2060 show:

   • Cholesterol Levels: Total cholesterol 180 mg/dL; HDL 60 mg/dL; LDL 100 mg/dL—within normal limits.

   • Blood Sugar Levels: Fasting glucose 90 mg/dL—normal.

2. Patient has scheduled a routine physical examination for December 15, 2060, including a complete blood panel.

3. Advised to maintain a balanced diet and continue regular exercise to support overall health.

---

Signature:

[Patient's Name]

Report Templates @ Template.net