Medical History Form

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Medical History
Mt Lebanon Internal Medicine
300 Cedar Blvd., Pittsburgh, PA 15228
(412) 561-1484; FAX (412) 561-7145
Name: ___________________________________ Age: ______ Birth date: __________
SingleMarried
DivorcedWidowedSeparatedSpouse name: ___________________
Children (ages): __________________________________________________________
Occupation: _____________________________________________________________
Education: ______________________________________________________________
Allergies to medications, X-ray contrast, or other substances (please list the name of
medicine and type of reaction):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Medications (Prescription, over-the-counter, vitamins, dietary supplements, etc.)
Drug name
Dose Frequency
Drug name
Dose Frequency
_________________________________
____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
Past Medical History
Please list medical problem, year of occurrence, treatment, including hospitalizations, and
operations:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
MD Review____________________________________ Date: ____________________

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