Patient Medical History Form

Patient Information and Medical History
Patient Gender *
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Height (Feet' Inches'')
Patient Weight (Pounds)
Patient E-Mail*
example@example.com
Patient Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Medical History

Have you ever had any of the following? (Please check all that apply)
Skin

EczemaRosaceaPsoriasisAcneHivesOther
Ears/Eyes/Nose/Throat

Seasonal AllergiesSinus InfectionsEar InfectionsDeviated SeptumCataractsGlaucomaOther
Pulmonary and Allergies

COPDPneumoniaSleep ApneaRespiratory Tract InfectionAsthmaOther
Cardiovascular

High Blood PressureHigh CholesterolIrregular HeartbeatFaintingCoronary Artery DiseaseChest Pain (angina)Congestive Heart FailureHeart AttackStroke/TIAPacemaker/DefibrillatorOther
Gastrointestinal

GERD/Acid RefluxLactose IntoleranceStomach UlcersConstipationDiarrheaIrritable Bowel SyndromeCrohn's DiseaseUlcerative ColitisColon PolypsGI BleedDiverticulosis/DiverticulitisOther
Liver/Hepatic:

HepatitisCirrhosisGallstonesOther
Metabolic/Endocrine

HypothyroidismHyperthyroidismOverweightDiabetesDiabetic NeuropathyOther
Nephrology/Kidneys and Urinary

Prostate ConditionIncontinenceHypogonadism (Low Testosterone)Kidney StonesBlood in UrineChronic Kidney DiseaseOther
Musculoskeletal

OsteoarthritisTendonitisFibromyalgiaOsteoporosis/OsteopeniaOther
Rheumatology

LupusRheumatoid arthritisAnkylosing spondylitisGoutOther
Blood disorder/Hematologic

Bleeding DisordersAnemiaLeukemiaHx of blood clots/DVTOther
Psych/Mental Health and Neurology

AnxietyBipolarDepressionSchizophreniaInsomniaPanic AttacksSeizuresMigraine HeadachesMenstrual HeadachesSinus HeadachesTension HeadachesMultiple SclerosisNeuropathyOther
Other illnesses/Medical conditions:
Please list your Current Medications
Please list any Surgeries or Hospitalizations and Dates of Each
Please list any drug allergies
Health Habits
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Do you have any history of recreational drug use?
Do you use any nicotine products? (Vape, Chewing tobacco, etc)
Include other comments regarding your Medical History
Name

First NameLast Name
Should be Empty:

Patient Information and Medical History

Patient Medical History

Health Habits