• MEDICAL HISTORY FORM

  • DOB:
     - -
  • DATE:
     - -
  • Format: (000) 000-0000.

  • Please answer all questions. If you do not know the answer, or do not understand the question, insert a question mark in the space.

  • GENERAL HEALTH AND HABITS:

  • Characterize your present health status:

  • Exercise:

  • Do you exercise regularly?

  • Smoking:

  • Do you smoke?
  • What do you smoke?

  • Nutrition:

  • Your weight:

  • Your appetite:

  • Alcohol/Beverages:

  • Estimate the amount of alcohol you drink regularly:

  • Did you formerly drink alcohol but have permanently stopped?

  • PAST MEDICAL AND SURGICAL HISTORY:

  • REVIEW OF SYSTEMS

  • Answers all questions. If you do not know the answer or do not understand the question, insert a question mark.
    Have you ever had any of the following? If so, indicate when.       LEAVE NO BLANKS!!!

  • RESPIRATORY

  • Rows

  • DIGESTIVE

  • Rows

  • CIRCULATORY

  • Rows

  • ENDOCRINOLOGY

  • Rows

  • JOINTS

  • Rows

  • CUTANEOUS

  • Rows

  • URINARY

  • Rows

  • OBSTETRIC & GYNECOLOGICAL

  • Rows

  • HEMATOLOGY & ONCOLOGY

  • Rows

  • NEUROLOGICAL

  • Rows

  • MOOD

  • Rows

  • SPECIAL SENSE

  • Rows
  • Rows

  • ALLERGY & IMMUNOLOGY

  • Rows

  • CURRENT ALLERGIES TO MEDICATIONS / FOOD ALLERGIES / ANY ALLERGIES

  • MEDICATION LIST

  • PERSONAL HISTORY

  • Have any of your blood relatives had the following?

  • FAMILY HEALTH

  • Rows
  • Date:
     - -
  • Help with Form?
  • Should be Empty: