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