Medical History Form

Name

First Name Last Name

Check the conditions that you have, or have had in the past: *

Asthma Cancer Cardiac disease Diabetes Hypertension Psychiatric disorder Epilepsy AIDS/HIV Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Blood Disease Blood Transfusion Breathing Problems Bruise Easily Chemotherapy Cold sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Drug Addiction Easily Winded Emphysema Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B Hepatitis C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Jaw Pain Parathyroid Disease Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tiberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice None of the above

Are you currently taking any medication? *

Yes No

Current Medications you are taking:

Do you use or do you have history of using tobacco? *

Do you use or do you have history of using illegal drugs? *

How often do you consume alcohol? *

Daily Weekly Monthly Occasionally Never

Signature

Clear