Endo Medical History Form

General Patient Information
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Gender*
Patient Height
In Feet and Inches
Patient Weight (pounds)*
Numbers only
Patient E-Mail*
Reason for seeing the doctor:*
Patient Medical History
Please list all medications : NAME, STRENGTH, HOW OFTEN, and REASON FOR TAKING. Enter NONE if not taking any. *
Please list all Vitamins, supplements, or 'nutriceuticals' that you are taking, and how often
Please list all drug allergies and what your reaction was to the drug or enter NONE*
Please list any Operations or NONE*
Please list any hospital stays. Include Month/Year, the admission reason, how long in hospital, and which hospital.*
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisSTD or Venereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Family History

Please fill out your family medical history as best you can.

	Status Living or Deceased	Age	Year of Birth	Health Problems or cause of death
Mother
Father
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Brother 1
Brother 2
Brother 3
Sister 1
Sister 2
Sister 3
Uncles
Aunts
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Other relatives

Social History
Who else lives in your household ?
What kind of work do you do?*
Are you exposed to any infections or toxins at work? Please list them here. Enter NONE if there are none.*
How much school have you completed ?

Middle schoolSome high schoolGraduated high school or GEDSome collegeAssociates DegreeBachelors DegreeGraduate Degree
Health Habits
Exercise*

Never1-2 days3-4 days5+ days
Eating following a diet*

Diabetic diet but not carb countingCarb CountingI have a strict dietI have a loose dietI don't have a diet planOther
Alcohol Consumption*

I don't drink0 -2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?*

Never smokedQuit smoking0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History or health concerns that you have today.
Signature
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General Patient Information