Medical History Form

Medical History Form
Do you have now or have you ever had any of the following conditions? Check only those that apply.
High Blood PressureStrokeChest PainHeart AttackDefribrilatorPacemakerMitral Vlave ProlapseAbnormal EKG/Stress TestTaking Anticoagulants
Seizures/FaintingDementiaParkinson'sOther
COPD or EmphysemaAsthmaShortness of BreatheUse of OxygenTobacco Use
Pain in JointsSwelling in JointsArtificial Joint(s)OsteoarthritisRheumatoid ArthritisScoliosisOsteopenia/Osteoporosis
CancerDiabetes: Type I/IIThyroid AbnormalityBladder/Bowel ProblemsBleeding DisorderHistory of HIVHistory of HepatitisPregnancy (or trying?)Dizziness/VertigoWeight Loss/GainFalls/Near FallsOther
DepressionAnxietyOther
YesNo
If yes, please explain.
YesNo
Adverse reactions to medications?
List all medications you are currently taking (include OTC, herbals, supplements, vitamins, or attach list):
Please list any surgical procedures you have had (and dates)
Patient Name*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date
Should be Empty: