Medical History Form
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710815 Bathurst St., Richmond Hill, ON L4C 9Y2
Tel.: 905-737-5559, fax: 905-737-5556
Your name _________________________________________________________________
Address(incl postal code): _______________________________________________
Date of Birth (day/month/year): ____/____/_____
Age:
Phone #:____________________
Please list your chief concern(s):_________________________________________
Please list any current medications and/or
supplements:__________________________________________________________
How did you hear about us: ____________________________________________________
Review of Systems
Y
A condition you have now
N
A condition you have NEVER had
P
A condition you have had in the past
Responses and Comments:
1. GENERAL
Weight
Weight 1 year ago
Maximum weight
When
Height
Fatigue/Weakness
Y P
N
Fever/Chills
Y P
N
2. SKIN
Rashes
Y P
N
Eczema, hives
Y P
N
Acne, boils
Y P
N
Itching
Y P
N
Color change
Y P
N
Lumps
Y P
N
Night sweats
Y P
N
Dryness/Moistness
Y P
N
Temperature
Y P
N
Nail changes
Y P
N
Change in mole
Y P
N
Skin cancer
Y P
N
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Parent category: Medical