Health Maintenance Form
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2Office Use Only: MRN # ________________________________
Updated 02/2013
Health Maintenance
Patient’s Name _______________________________________________ DOB ______________ Date __________________
Present Complaint ________________________________________________________________________________________
Medical Doctor ______________________________________ Referring Physician __________________________________
Preferred Pharmacy (Please include city and state) _______________________________________________________________
Medications and Dosages
(may attach list or write on back): __________________________________________________
Medication Allergies
: __________________________________________________________________________________
Active Problems
Please check
if any of the following are currently active problems for the above named patient:
+ Latex Allergy Test
Hypertension
Hypothyroidism
Obstructive Sleep Apnea
Glaucoma
Asthma
Osteoporosis
HIV Infection
Allergic Rhinitis
Emphysema
Diabetes
Blood Clotting Problem
Hearing Loss
Stomach Acid Reflux
Arthritis
Cancer (location ___________)
Abnormal Heart Rhythm
Hepatitis
Rheumatoid Arthritis
Using CPAP
Heart Artery Blockage
High Cholesterol
Migraine Headache
Heart Failure
Hyperthyroidism
Seizure
Other Medical Problems _______________________________________________________________
Past Medical History
Please check
if the above named patient has been treated in the past for any of the following problems:
Heart Attack (year _________)
Hepatitis
Cancer (location _______________)
Stroke
Other past Medical Problems ___________________________________________________________
# of Pregnancies _______
# of Children _____
Living: sons_____ dgts_____
Deceased: sons____ dgts______
Past Surgical History
Please check
if the above named patient has had anesthesia for any of the following surgeries:
Wisdom tooth extraction
Coronary Artery Bypass
Hernia Repair
Knee Surgery
Pacemaker Placement
Heart Valve Replacement
Kidney Removed
Foot Surgery
Cataract removal
Breast Biopsy
Kidney Stone Removal
Brain Surgery
Ear Surgery
Mastectomy
Hysterectomy
Neck Disc Surgery
Nasal Surgery
Stomach Surgery
Tubal Ligation (Tubes Tied)
Back Disc Surgery
Tonsillectomy
Intestine Surgery
C-section
Carpal Tunnel Repair
Thyroid Surgery
Appendectomy
Shoulder Surgery
Vascular Surgery
Gall Bladder Removal
Hip Surgery
Other Surgeries ________________________________________________________________________________________
Past Family History
Please check
if there is a Family History for any of the following for the above named patient:
Cancer (Location _____________)
Osteoporosis
Heart Disease
Diabetes
Bleeding Problems
Rheumatoid Arthritis
Hearing Loss
Migraine Headache
Mental Retardation
Seasonal Allergies
Seizures
Hypertension
Alzheimer’s
Blood Clots
Parkinson’s
Stroke
Other Family Medical Problems ____________________________________________________________
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Parent category: Medical