Medical History Form

ADVERTISEMENT

Medical History:
Check if you have had any of these Medical Problems in the Past:
MAJOR ILLNESS
YES
NO
MAJOR ILLNESS
YES
NO
Anemia
Liver Disease
Arthritis
Kidney Disease
Heart Arrythmia/Palpitations
Loss of Vision
Asthma
Mitral Valve Prolapse
Bleeding Problems
Neuropathy
Blood Clots
Paralysis
Cancer: Type _______________
Peripheral Vascular Disease
Chest pain/Angina
Pneumonia
Diabetes
Psychiatric Illness
Gall Bladder Disease
Pulmonary Embolism
Gastric Ulcers
Reflux
Glaucoma
Skin Ulcer/Breakdown
Heart Attack
Steroid Use
Heart Failure
Stroke
Heart Murmur
Thyroid Disease
Hepatitis B
Tuberculosis – TB
Hepatitis C
Urinary Infections
High Blood Pressure
Valve Disorders (heart)
HIV/AIDS
Wound Healing Problems
Immune Deficiency
OTHER: _________________
Please list any operations/surgeries you have had:
SURGERY/ REASON
YEAR
SURGERY/REASON
YEAR
1)
5)
2)
6)
3)
7)
4)
8)
Please list any Medications that you are currently taking:
MEDICATION
DOSE
DOCTOR
MEDICATION
DOSE DOCTOR
1)
6)
2)
7)
3)
8)
4)
9)
5)
10)
Do you have any allergies to medications/substances?
Yes
No
_________________________________________________________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2