Medical History Form Page 2
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4Central Texas Surgical Associates
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ALLERGIES or REACTIONS:
None
Latex
Medication
Reaction or Side Effect
FAMILY HISTORY:
Please check all that apply.
Medical Condition
Mom
Dad
Sister
Brother
Daughter
Son
Other
Anesthesia Problem
Asthma
Bleeding Problems
Breast Cancer
Colon Cancer
Melanoma
Thyroid Cancer
Parathyroid Cancer
Prostate Cancer
Diabetes
Heart Attack
High Blood Pressure
Kidney Disease
Leukemia
Lupus
Lymphoma
Stroke
Vascular Disease
SOCIAL HISTORY
Tobacco Use
Cigarettes
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Never
Current Smoker: packs/day _____ # of years _____
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Quit: Date _____ How many years did you smoke? _____
Other Tobacco:
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Pipe
Cigar
Snuff
Chew
Alcohol Use
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No
Yes: # drinks/week _____
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