Medical History Form

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Medical History Form
Name: ______________________________________
Date of Birth: ____/____/________
Today’s Date: ____/____/________
Have you ever had any of the medical problems listed below? For any “yes” answers please circle and give details:
Diabetes
High Blood Pressure
Stroke
High Cholesterol
Heart Problems
Hepatitis (A, B, or C)
Gallstones
Kidney Stones
Kidney Infections
Seizures
Migraines
Thyroid Problems
Blood Clots in your legs or lungs
Asthma
Pneumonia
Tuberculosis
Depression
Anxiety
Eating Disorder
Bipolar Disorder
Alcoholism
Drug Use
Blood Transfusions
Anemia
Gastrointestinal Problems
Victim of Domestic Violence
Victim of Sexual Abuse
Please list any operations or hospitalizations you have had in your lifetime:
Year
Type of Operation or Reason for
Details/
Hospitalization
Comments
What is the name of your family doctor, internist, or PCP? ______________________________________

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