Medical History Worksheet (Page 2 of 3) in pdf

Medical History Worksheet Page 2

Please list all of your previous surgeries and approximate year/decade performed:

I have never had surgery



Surgery

When?

Surgery

When?

If you are currently taking medication on a regular basis, please list their names:

I am not currently taking any prescription medications



If you are allergic to any medications, please list the medication and its effect on you:

I have no allergies to medications



Name

Effect

Name

Effect

Please tell us about yourself:

How tall are you? _________________________ How much do you weigh? __________________

Which is your dominant (or writing) hand? Right  Left  Both 

How often do you drink alcoholic beverages?

None  Occasional  Moderate  Heavy 

Do you use tobacco products? Yes  No 

If Yes, Cigarettes Cigars Pipe Chew How much/day? ________ Individual  Packs 

In what sports are you a regular participant? __________________________________________________

Medical History Worksheet Page 2