Medical History Form

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Medical   H istory   F orm  
 
 
Patient   N ame:   _ ____________________________________________________________  
Date   o f   B irth:   _ _____________________  
 
Today’s   D ate:_______________________  
 
 
 
 
Current   w eight:   _ __________________  
 
 
 
 
 
 
 
 
 
Current   h eight:   _ ___________________  
Reason   f or   V isit:   _ _______________________________________________________________  
q  
q  
q  
How   D id   Y ou   H ear   A bout   U s?    
q  
D octor   R eferral              
I nternet              
F riend   R eferral          
S ocial   M edia   ( e.g.,   Y elp)  
 
 
 
 
q  
O ther   _ __________________________________    
 
SOCIAL   H ISTORY  
Do   y ou   s moke?  
Yes  
No  
 
If   y es,   h ow   m any   p acks   p er   d ay?   _ _______________________________  
Have   y ou   e ver   s moked?  
Yes  
No  
 
For   h ow   m any   y ears?   _ ___________________________________________  
Do   y ou   u se   a ny   s treet   d rugs?  
Yes  
No  
 
 
Do   y ou   d rink   a lcohol?  
Yes  
No  
 
If   y es,   h ow   m any   d rinks   ( average)   p er   w eek?   _ ________________  
Do   y ou   e xercise   r egularly?  
Yes  
No  
 
If   y es,   h ow   m any   t imes   ( average)   p er   w eek?   _ _________________  
 
 
PHARMACY   I NFORMATION  
Pharmacy   N ame:   _ _________________________________________________________________   Tel:   _ ____________________________________  
Address:   _ __________________________________________________________________________    
 
MEDICATIONS   A ND   S UPPLEMENTS  
Please   l ist   a ll   m edications   a nd   s upplements   y ou   a re   c urrently   t aking.    
 
Name   o f   M edication  
Dose   a nd   F requency  
Reason   f or   t aking  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do   y ou   t ake   a ny   b lood   t hinners?  
____   N o    
____   C oumadin    
____   A spirin  
____   O ther:   _ ______________________________  
 
ALLERGIES  
_____   I   h ave   n o   k nown   a llergies  
_____   I   h ave   t he   f ollowing   a llergies:  
 
Medication/Substance  
Reaction  
 
 
 
 
 
FAMILY   H ISTORY  
Does   o r   d id   a nyone   i n   y our   f amily   h ave   a ny   o f   t he   f ollowing   c onditions?  
 
Condition  
Relationship  
Description  
q   C ancer
 
 
 
q   B leeding   o r   c lotting   d isorders
 
 
 
q   D iabetes
 
 
 
q   H eart   a ttack
 
 
 
q   S troke  
 
 
q   O ther  
 
 
(Please   t urn   t o   o ther   s ide.)

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