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