Medical History
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1
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3Medical History
Name:
Date of Birth:
Family Physician:
Phone:
Present Status:
At the present time what is the state of your health?
Excellent Good Fair Poor
Are you under a doctor’s care at the present time?
Yes
No
If yes, why?:_________________________________________________________________
Please list all medications and supplements which you are currently taking:
_________________________________________________________________________________
_________________________________________________________________________________
Please list all known allergies to medications, foods or other allergens:
________________________________________________
Medical History (circle all that apply)
High Blood Pressure
Measles
Tonsillitis
Diabetes
Mumps
Arthritis
Heart Disease
Scarlet Fever
Osteoporosis
Frequent Headaches
Whooping Cough
Alcohol Abuse
Migraines
Bleeding Disorder
Blood Transfusion
Glaucoma
Gout
Cancer
Edema/Swelling
Constipation
Pneumonia
Depression
Gallbladder Disease
Polio
Kidney Disease
Liver Disease
Drug Abuse
Lung Disease
Chicken Pox
Eating Disorder
Rheumatic Fever
Psychiatric Illness
Tuberculosis
Ulcers
Thyroid Disease
Other:
Anemia
Jaundice
Ob/Gyn History:
Menstrual: Onset age:
Are they Regular?
Yes
No
Last menstrual Period?
Hormone Replacement Therapy
Yes
No
Current Method of Birth Control?
Last Pap Smear (date)___________
Pregnancies
Yes
No
Number:
Dates:
___________
Last Mammogram (date)______________
General Medical History
Date of last physical exam
Please list all current illnesses: _________________________________________________________
Please list all serious illnesses:
Please list all serious injuries:_________________________________
Please list all surgeries:
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Parent category: Medical