MEDICAL HISTORY FORM

Patient Name

Patient's Date of Birth

Do you

<>Smoke?

Packs per Day

Years Smoked

<>Drink Alcohol?

Drinks per Day

<>Drink Soda

Liters per Day

<>Drink Coffee

Cups per Day

List medications you are taking

List any alergies you have to drugs, food or other items

<>Are you currently under medical care for any reasons?

Please explain:

Primary Care Physician:

Name

Address

Phone

Women Only:

Age when menstural periods began:

<>Are your periods regular?

How often?

How many days do your periods last?

How many times have you been pregnant?

How many children born alive

List all operations:

Operation Performed

Year

Hospital

Doctor

Does any relative (parents, grandparents, children) have had any of the conditions listed below:

<>Anemia

<>Asthma

<>Bleeding Tendencies

<>Cancer

<>Colitis

<>Diabetes

<>Emphysema

<>Gout

<>High Blood Pressure

<>Heart Disease

<>Kidney Disease

<>Mental Illness

<>Seizures

<>Stroke

<>Tuberculosis

<>Ulcers

Other

Have you had any of the following illnesses:

Please list the date (if known) of your last,

X-ray

EKG

Blood Test

DateLastDoctorVisit

Submit

Medical History