Medical History Form
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2MEDICAL HISTORY FORM
Name__________________________________________________ Date____________
Address_________________________________________________________________
City_______________________________ State_______________ Zip______________
Home#_________________ Work #__________________ Cell # _________________
Email __________________________________________________________________
Physician’s Name___________________________ Pharmacy______________________
Please Circle if You Have Any of the Following Medical Conditions
Abnormal Bleeding
Glaucoma
Tuberculosis
Alcohol Abuse
Hay Fever
Ulcers
Allergies
Heart Attack
Venereal Disease
Anemia
Heart Surgery
Yellow Jaundice
Angina Pectoris
Hemophilia
ALERGIES
Arthritis
Hepatitis A
(Please Circle)
Artificial Bones
Hepatitis B
Aspirin
Artificial Heart Valve
High Blood Pressure
Codeine
Asthma
HIV+ AIDS
Dental Anesthetics
Blood Transfusion
Kidney Problems
Erythromycin
Cancer-Chemotherapy
Liver Disease
Jewelry
Colitis
Low Blood Pressure
Latex
Congenital Heart Defect
Mitral Valve Prolapse
Metals
Cosmetic Surgery
Pneumocystitis
Penicillin
Diabetes
Psychiatric Problems
Tetracycline
Difficulty Breathing
Radiation Therapy
Other_____________
Drug Abuse
Rheumatic Fever
__________________
Emphysema
Seizures
__________________
Epilepsy
Sickle Cell Disease
__________________
Fainting Spells
Sinus Problems
Fever Blisters
Stroke
Frequent Headaches
Thyroid Problems
Do you smoke or use tobacco? ____________________
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Parent category: Medical