Medical History Form

100% complete form 2 of 2

Patient Information

Physician Information

Please list all of the physicians that you see consistently.

Physician's Name Specialty Phone Number
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Past Medical History

Are you allergic to any medications? If so, please list them and describe your reaction:

Medication Reaction
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If you do not have any allergies, please check "No Allergies."

Are you allergic to any of the following?

       

Do you have any problems with anesthesia?

   

Do you have a history of motion sickness?

   

Do you have a recent history or taking steroid medication?

   

Have you ever had a blood transfusion?

   

Do you have a history of blood clots?

   

Do you or any family member in your household suffer from frequent infections?

   

Primary Language:

       
Secondary Language (if applicable):

Please list any and all prescription, non-prescription, and over the counter medications, home remedies, vitamins, birth control pills, inhalers, etc. that you currently take.

Medication Dose (e.g. mg/pill) Frequency
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Please list all past surgical procedures, major or minor, that you have had:

Please list all major illnesses, accidents of injury, or hospitalizations you have had:

Daily Routines

Tobacco Use

Smoke cigarettes:

       

(If you do not use tobacco products, please skip to alcohol use)

Other Tobacco Products:

           

Alcohol Use

Do you drink alcohol?

       
       

Do you drink caffeinated beverages?

   
Type:        
Drug Use

Do you use marijuana or recreational drugs?

   

Have you ever used needles to inject drugs?

   
Exercise

Do you exercise regularly?

   

What is your typical exercise regimen?

How would you rate your diet?

           

Are you on any kind of special diet?

   

If yes, please explain:

Would you like advice on your diet?

   

Social History

Women's Health History

Is there a chance that you are pregnant?

   

Are you breastfeeding?

   

Family Health

Select any problems a family member has had an indicate your relationship.

Disease Family Member(s) Disease Family Member(s)
General Health Factors

Please make a mark next to any of the following persistent symptoms you have had in the past few months. Read through every section and check “No Problems” if none of the symptoms apply to you. If you have symptoms that are not listed, please list them on the space provided below.

General

 

Neurological

 

Respiratory

 

Digestive

 

Endocrine
Head/Eyes/Ears/Nose/Throat

 

Cardiovascular

 

Bladder/Kidney

 

Hematological
Other Medical Conditions
Preferred Pharmacy
Terms & Conditions
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Digital Signature

To confirm that you accept the information above, please enter your initials between two slashes into the box below. Example: John Doe would enter /JD/

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