Appendix C: Sample Medical History Form

Fill this out in English, have it translated professionally, and bring multiple copies to give to every new doctor.

PATIENT MEDICAL PASSPORT

Personal Information

Name: _________________________

Date of Birth: _______

Passport #: _____________________

Nationality: ____________________

Blood Type: ______

Primary Medical Problem & Reason for This Visit

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Current Medications & Supplements

1. _________________ Dose: _______ How Often: _______

2. _________________ Dose: _______ How Often: _______

3. (List ALL, including vitamins and herbs)

Drug Allergies & Reactions

1. _________________ Reaction: ____________________

2. _________________ Reaction: ____________________

Past Medical History (Major Illnesses, Surgeries, Hospitalizations)

• Year: _______ Condition/Surgery: ________________________ Hospital: ______________

• Year: _______ Condition/Surgery: ________________________ Hospital: ______________

Family History (Parents, Siblings)

Father: Alive/Deceased. Health Conditions: _________________________

Mother: Alive/Deceased. Health Conditions: _________________________

Social History

Smoker? No / Former (____ years ago) / Current (____ packs/day)

Alcohol: No / Occasionally / Regularly (____ drinks/week)

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