Medical History
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?
*
Yes
No
Do you use or do you have history of using illegal drugs?
*
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Signature
Clear
Submit
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