Medical History Form Page 2
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1
2
3Asthma/allergies
Heart Problems
Circulatory Problems (Bleeding)
Convulsions
Head Injuries
Muscular-Skeletal Injuries
Back Injury
Gastro-intestinal problems
Arthritis/Fibromyalgia
Other Injuries
Other Illnesses
Hearing Problems
Vision Problems
Food Intolerance(s)
Dietary Restrictions
Sleep Problems
:
EXPLANATIONS AND COMMENTS FOR CHECKED ITEMS
Comments—seriousness of the above condition, specific treatment(s), responses
to or outcomes of treatment, and any residual symptoms—regarding any prior
medical conditions:
Comments—seriousness of the above condition, specific treatment(s), responses
to or outcomes of treatment, and any residual symptoms— regarding any current
medical conditions, treatment approach and response to treatment:
:
M
M
E
E
D
D
I
I
C
C
A
A
T
T
I
I
O
O
N
N
H
H
I
I
S
S
T
T
O
O
R
R
Y
Y
O
O
R
R
R
R
E
E
C
C
O
O
R
R
D
D
Please list all the medications—psychiatric, non-psychiatric, botanical and
naturopathic—that you are currently taking:
Please list all the psychiatric medications you have previously taken:
Rev. 7/07
Medical History Form
2
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