Medical History Form (Page 2 of 2) in pdf

MEDICAL H ISTORY

Are y ou c urrently h aving a ny p roblems o r c onditions r elated t o t he f ollowing?

Constitutional

Neurological

Fevers

Yes

In t he P ast

Headaches

Yes No

In t he P ast

Chills

Yes

In t he P ast

Dizzy s pells

Yes No

In t he P ast

Weight g ain/loss

Yes

In t he P ast

Numbness/Tingling

Yes No

In t he P ast

Excessive f atigue

Yes

In t he P ast

Ongoing I nfection

Yes

Eyes

Endocrine

Blurred v ision

Yes No

In t he P ast

Diabetes/High b lood s ugar

Yes

In t he P ast

Double v ision

Yes No

In t he P ast

Thyroid p roblems

Yes

In t he P ast

Excessive T hirst

Yes

In t he P ast

Gastrointestinal

Abdominal p ain

Yes No

In t he P ast

Cardiovascular

Heartburn/indigestion

Yes No

In t he P ast

Chest p ain ( angina)

Yes

In t he P ast

Abnormal b owel m vmts

Yes No

In t he P ast

Heart f ailure ( CHF)

Yes

In t he P ast

Irregular h eartbeat

Yes

In t he P ast

Integument ( Skin)

High b lood p ressure

Yes

In t he P ast

Rashes

Yes No

In t he P ast

Low b lood p ressure

Yes

In t he P ast

Acne

Yes No

In t he P ast

Blood c lots ( DVT o r P E)

Yes

In t he P ast

Persistent i tching

Yes No

In t he P ast

Bleeding d isorders

Yes

In t he P ast

Psoriasis

Yes No

In t he P ast

Respiratory

Psychologic

Wheezing

Yes

In t he P ast

Depression

Yes No

In t he P ast

Coughing

Yes

In t he P ast

Suicidal t houghts

Yes No

In t he P ast

Shortness o f b reath

Yes

In t he P ast

Genitourinary

Breast

Urinary f requency

Yes No

In t he P ast

Breast p ain

Yes

In t he P ast

Urinary r etention

Yes No

In t he P ast

Nipple d ischarge

Yes

In t he P ast

Painful u rination

Yes No

In t he P ast

Breast l umps o r m asses

Yes

In t he P ast

Unusual v aginal d ischarge

Yes No

In t he P ast

Abnormal m ammogram

Yes

In t he P ast

Unusual v aginal b leeding

Yes No

In t he P ast

Medical C onditions

Surgery/Procedure

Date

Reason f or s urgery

Have y ou e ver h ad a c omplication r elated t o a nesthesia?

Yes

If y es, p lease d escribe:__________________________________________________________________________________________________________

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing

incorrect i nformation c an b e d angerous t o m y h ealth.

: _ _________________________________________________________

: _ ___________________

SIGNATURE O F P ATIENT, P ARENT o r G UARDIAN

D ATE

Medical History Form Page 2

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