Health History Form
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1
2
3HEALTH HISTORY
Patient Name______________________________________________ Today’s Date____________________
Age:________________
Birthdate:______________________
Mail Order Pharmacy Name/Address:
__________________________________________________________
Phone:____________________________________
Local Pharmacy Name/Address:
______________________________________________________________
Phone: ___________________________________
Allergies
?
(Circle)
Yes (if yes, please list below) or No
______________________________________________________________________________________
______________________________________________________________________________________
Medication List
Please list all medications: Prescription/over the counter/vitamins/supplements
List dosage and how often you take Example: Flomax 0.4 mg 1 tablet a day
Name
Dose
How often per Day?
1.________________________________
__________
________________________________
2.________________________________
__________
________________________________
3.________________________________
__________
________________________________
4.________________________________
__________
________________________________
5.________________________________
__________
________________________________
6.________________________________
__________
________________________________
7.________________________________
__________
________________________________
8.________________________________
__________
________________________________
9.________________________________
__________
________________________________
10.________________________________
__________
________________________________
Surgical History
List all Surgery from childhood to present including year of surgery. Example: Tonsils removed 1989
1.______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________
4.______________________________________________________________________________________
5.______________________________________________________________________________________
6.______________________________________________________________________________________
7.______________________________________________________________________________________
(OVER)
1
HealthHistory
R ev.
5 /1/2013
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