PAST MEDICAL HISTORY FORM - Electronic Version

Please list ALL current medication(s) AND supplements:

Rows	Current Medication (One medication per line)	Reason for taking
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2
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5
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8

Current & Past Medical History*

No ongoing medical problemsHypertension (high blood pressure)Past myocardial infarction (Heart Attack)AsthmaUlcer disease/GERDKidney diseaseHepatitis or liver diseaseRheumatologic joint diseaseHIV/AIDSThyroid Disorder
Bleeding or Clotting Disorders:*
If yes, please specify:*
Bowel Disease:*
If yes, please specify:
Diabetes*

YesNoYes, I am insulin dependent
Sleep Apnea*

YesNoYes, I use a CPAP
Cancer:*
If yes, please specify:
Previous MRSA/Staph or other infections:*
If yes, please specify location
Family history of malignant hyperthermia*
If yes, which family member
Other medical history - Please explain:
Since last September 1st, have you received: (Check those that apply)

Influenza (flu) vaccine?Pneumococcal (Pneumonia) vaccine?COVID-19 Vaccine?
Psychological History:*

Medical treatment for depressionAnxietyNo past psychological history
Other psychological - please explain:
Latex Allergy:*
Medication Allergies:*

Medication Allergies

Rows	Medication Name (One medication per line)	Reaction
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Please list all past surgeries:

Rows	Surgery Description (One procedure per line)	Date of Procedure
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2
3
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Family History*

Rows	MOM	DAD	SISTER(s)	BROTHER(s)	MAT GRMTH	MAT GRFTH	PAT GRMTH	PAT GRFTH
Status: A=Alive D=Decd U=Unk
Place a (X) next to those that apply
Osteoarthritis
Cancer
Diabetes
Stoke
Heart Attacks
Rheumatoid Arthritis
Bleeding Tendencies
Anesthetic problems or complications

Tobacco User*
How many packs per day do you smoke?
Other tobacco products? - Please specify:
Drug Use? (Specify type of drug):
Alcohol Use?*
How often do you have an alcoholic beverage?
Marital Status*
Number of Children
Hobbies
Current Occupation
Place of Employment
Job Status
Time with present employer
Primary Care Physician Name
Primary Care Physician Phone Number
Format: (000) 000-0000.
Referring Physician Name
Referring Physician Phone Number
Format: (000) 000-0000.
I agree that the Past Medical History information completed is correct to the best of my knowledge.
Patient/Guardian Signature*
Date*

MonthDayYear
Date
Should be Empty: