Patient Medical History Page 2
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5Personal Medical History: Check if you had any of these medical problems in the past.
Major illness
Yes
Major Illness
Yes
Hepatitis ⧠A ⧠B ⧠C
Anemia
Anxiety
High blood Pressure
Arthritis/Joint Pain
High Cholesterol
Asthma
Hypothyroid
Blood clot/DVT
Hyperthyroid
Blood Transfusions
Interstitial Cystitis
Breast Cancer
IBS (irritable bowel syndrome)
Cancer- list type:
Jaundice
Chronic Lung Disease
Migraines
Depression
Osteopenia
Diabetes Type1
Osteoporosis
Diabetes Type 2
Ovarian Cancer
Fibroids
Seizures
Fracture
Sexually Transmitted Disease
GERD
Stroke
Heart Disease
Tuberculosis-TB
Other:____________________________________________________________________________________________
__________________________________________________________________________________________________
Past Surgical History: ⧠ No past surgical history
Year
Surgery
Complications?
Current Medications: ⧠ None
If there is not sufficient space please attach copy of medications list to this form.
Prescription and non-prescription medicine, vitamins, home remedies, birth control pills, herbs:
Medication
Dosage (mg)
Frequency
Prescribing Physician
2.
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Parent category: Medical