Medical History Form

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Medical History Form
Patient’s Last Name_______________________ Middle Intial ______ First Name________________________________
Are you currently under the care of a physician?  No  Yes
For what reason: ___________________________________________________________________________________
When was your last physical exam? ___________________________________________________________________
Physician’s Name __________________________________________________________________________________
Address _________________________________________ Phone ___________________ Last time seen ___________
Have you ever been hospitalized?  No  Yes
___________________________________________________________________________________
If yes, please explain
Are you taking any prescription medications?  No  Yes
___________________________________________________________________________________
If yes, please explain
Are you taking any over the counter medications?  No  Yes
___________________________________________________________________________________
If yes, please explain
Do you have any allergies?  No  Yes
___________________________________________________________________________________
If yes, please explain
Are you allergic to any medications or other substances?  No  Yes
___________________________________________________________________________________
If yes, please explain
Do you have any problems with antibiotics or anesthetics?  No  Yes
___________________________________________________________________________________
If yes, please explain
Do you take appetite suppressants?  No  Yes Name of product: _________________________________________
Have you ever had any of the following disease or medical conditions?
 No
 Yes
 No
 Yes
Heart Attack/Stroke
Epilepsy
 No
 Yes
 No
 Yes
Cancer/Chemotherapy
Seizures
 No
 Yes
 No
 Yes
Heart Murmur
Fainting
 No
 Yes
 No
 Yes
Rheumatic Fever
Diabetes
 No
 Yes
 No
 Yes
HIV/AIDS
Tuberculosis
 No
 Yes
 No
 Yes
Hepatitis A
Hemophilia
 No
 Yes
 No
 Yes
Hepatitis B
Blood Transfusion
 No
 Yes
 No
 Yes
Hepatitis C
High Blood Pressure
 No
 Yes
 No
 Yes
Hepatitis D
Low Blood Pressure
 No
 Yes
 No
 Yes
Anemia
Radiation Treatment
 No
 Yes
 Yes
 No
Mitral Valve Prolapse
Kidney Problems
 No
 Yes
 No
 Yes
Artificial Joints / hip or knee
Artificial Valves (heart)
 No
 Yes
 No
 Yes
Sinus Problems
Severe Headaches
 No
 Yes
 No
 Yes
Asthma
Frequent Headaches
 No
 Yes
 No
 Yes
Difficulty Breathing
Emphysema
 No
 Yes
 No
 Yes
Venereal Disease
Shingles
 No
 Yes
 No
 Yes
Herpes Type I
Herpes Types II
 No
 Yes
 No
 Yes
Heart Surgery
Pace Maker
 No
 Yes
 No
 Yes
Psychiatric Problems
Glaucoma
 No
 Yes
 No
 Yes
Do You Smoke?
Do You Consume Alcohol?
Are You Allergic To Any of The Following?
 No
 Yes
 No
 Yes
Penicillin
Codeine
 No
 Yes
 No
 Yes
Aspirin
Tetracycline
 No
 Yes
 No
 Yes
Erythromycin
Germicides/Pesticides
 No
 Yes
 No
 Yes
Latex/or Rubber Products
Other____________________
For Women Only:
 No
 Yes
 No
 Yes
Taking Birth Control Pills
Pregnant/No. of Months: _____
 No
 Yes
 No
 Yes
Nursing?
Hormone Therapy
Doctor Signature:________________________________________________________ Date: __________________________
Patient Signature_________________________________________________________ Date ___________________________
Medical History Form

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