Medical History Form

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Medical History Form
Date _________________
Name:
Last ___________________First___________________
Home Phone
Middle__________________
(___) _____________
SS# _________-______-____________
Business Phone
( ___) _____________
Address:________________________________________________
City _________________________
State _____________
Zip Code _______________
Occupation ______________________________________________
Date of Birth ____________
Sex
Height
Weight
Closest Relative
Single _____
Spouse’s Name
_____________________
M
F
_____
______
_____________________
Phone # ________________
Married ____
If you are completing this form for another person, what is your relationship to that person?
___________________________________________________________
Referred by__________________________________________________
For the following questions, circle yes or no, whichever applies. Your answers are for our records only
and will be considered confidential. Please note that during your initial visit you will be asked some
questions about your responses to this questionnaire and there may be additional questions concerning
your health.
1. Are you in good health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
2. Has there been any change in your general health within the past year? . . . . . . . . . . . . . . . . . . .
Yes
No
3. The date of your most recent physical examination was ___________________________________
4. Are you now under the care of a physician? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If so, what is the condition being treated?__________________________________________
5. The name and the address of your physician(s) is _______________________________________
__________________________________________________________________________________
6. Have you had any serious illness, operation, or been hospitalized in the past 5 years? . . . . . . . . . .
Yes
No
If so, what was the illness or problem? ____________________________________________
7. Are you taking any medicine(s) including non-prescription medicine? . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If so, what medicine(s) are you taking? ____________________________________________
8. Do you have or have you had any of the following diseases or problems?
a. Damaged heart valves or artificial heart valves, incl. heart murmur or rheumatic heart disease .
Yes
No
b. Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, coronary
Yes
No
occlusion, high blood pressure, arteriosclerosis, stroke) .
1. Do you have chest pain upon exertion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
2. Are you ever short of breath after mild exercise or when lying down? . . . . . . . . . . . . .
Yes
No
3. Do your ankles swell?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
4. Do you have a heart defect? . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .
Yes
No
5. Do you have a cardiac pacemaker? . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .
Yes
No
c. Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
d. Sinus Trouble. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
e. Asthma or hay fever . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
f. Fainting spells or seizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
g. Persistent diarrhea or recent weight loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
h. Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
i. Hepatitis, jaundice or liver disease . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
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