Medical History Questionnaire printable pdf download

Medical History Questionnaire

MEDICAL HISTORY QUESTIONNAIRE

NAME: ____________________________________ DATE: _________________________

Do you have allergies to any medications or to Latex? YES or NO if YES, please list

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, cancer )

___________

List date/surgeries you have had (cataract, appendectomy, bypass)

MEDICATION LIST

Please list all medications you currently take (prescription & over the counter, including aspirin,

vitamins, herbal supplements, blood thinners and eye drops.

MEDICATIONS

EYE DROPS

(Circle those that apply)

REVIEW OF SYSTEMS

YES NO

DETAILS

GENERAL/CONSTITUTIONAL

Fever, weight loss, cancer (list type)

EARS, NOSE, THROAT

stuffy nose,

Cough, seasonal allergies

CARDIOVASCULAR

Heart disease,

High blood pressure, heart attack, angina

MUSCLES, BONES, JOINTS

Joint pain

Stiffness, arthritis, myasthenia gravis

GASTROINTESTINAL

upset stomach,

Diarrhea, constipation

GENITAL, KIDNEY, BLADDER

Kidney stones, enlarged prostate, incontinence

RESPIRATORY

Asthma, emphysema

SKIN

Acne, rosacea, skin cancer

Medical History Questionnaire