Medical History
Patient Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Date of Bith
/
Month
/
Day
Year
Date Picker Icon
Age
Height
Weight
BMI
Occupation
Marital Status
Single
Married
Widowed
Divorced
Children
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Current & Past Medical History
check appropriate box:
Rows
YES
NO
CARDIAC
Heart Attack, Irregular Heartbeat, Angina, Abnormal EKG
PULMONARY
Asthma, Emphysema, COPD, Tuberculosis, Abnormal Chest X Ray
INTESTINAL
Ulcers, Bleeding, Diverticulitis, Irritable Bowel Syndrome
MUSCULOSKELETAL
Arthritis, Joint Problems, Fractures Metal Plates/Pins
ABDOMINAL
Hiatal Hernia, GERD, Lap Band, Sleeve, Bypass Procedure
HEPATIC
Hepatitis A B C, Jaundice, Liver Disease
AUTOIMMUNE
Lupus, Scleroderma, Fibromyalgia, MS, Psoriasis, Rheumatoid Dx
CANCER
Active, In Treatment, Remission
ENDOCRINE
Diabetes, Thyroiditis, Hypothyroid, Insulin use
HEMATOLOGY
Abnormal Bleeding or Bruising, Blood Clots, Transfusion, Anemia
Blood Thinners: ASA, Warfarin, Coumadin, Xarelto, Eliquis, Pradaxa, Brilinta, Effient Plavix
HIV/AIDS
HIV, other Sexually Transmitted Diseases
NEUROLOGIC
Seizures, Strokes, Migraines, Dizziness, TIA, Sciatica, Numbness
PREGNANCY
Within 3 months of Vaginal Delivery or Breast Feeding
PSYCHIATRIC
Depression, Bipolar, Psychiatric Condition, Care or counselling
RENAL
Kidney Infection, Disease, Diminished Function
SLEEP APNEA
Excessive Snoring, Restlessness, Morning Fatigue, CPAP
VISION
Contacts, Poor Vision, Prescription Eye Drops, Glaucoma, Dry Eyes
DENTAL
Chipped or Cracked Teeth
EAR
Hearing aid
BREAST
Abnormal Mammogram, Tumors, Breast Biopsy, Breast Cancer
SKIN
Accutane Treatments, Chemotherapy, Radiation, Keloid Scarrinf, Poor healing,
MRSA Methicillin Resistant Staph / MDRO multi drug resistant organism
Physical Condition
Yes
No
If Yes, please check highest level you can perform comfortably:
Eat Dress Walk around House
Mow Lawn Climb Stairs Walk 1-2 Miles Bike
Jog or Run Singles Tennis Aerobic exercise
Any Current Acute Illnesses or Treatments?
Weight
loss lbs.
weight gain
pills stimulants
Disabilities
Med Alert Bracelets
Handicap parking
Permanent Injury or Disability Compensation
Surgical History
List date(s) and type(s) of surgery
Diet Pills
Phentermine
None
Other
Alcohol
None
Other
Recreational Drugs
None
Other
Drug Dependency / Rehabilitation
None
Other
Malpractice Litigation
Yes
None
If Yes, please explain:
Prior Cosmetic Surgeries?
Face
Body
Breast
Bariatric
None
Prior Anesthesia Complications
Malignant Hyperthermia
Anaphylaxis
Coma
Allergic
None
ALLERGIES
None
Allergic to:
CURRENT MEDS
None
List of all current meds:
Tobacco HX
None
Tobacco
E Cig
Cigars
Nicotine
PPD
Years Smoked
Date Quit
Dietary Supplements
None
List of dietary supplements
Family History
Cardiac
Bleeding
Anesthesia Reactions
Blood Clots
DVT
Pulmonary Emboli
Birth Control
Last Mammogram (date)
Abnormal Results
CT Scan
MRI
X-ray
Hormones and Steroids use
Should be Empty: