Patient Medical History Form

General Patient Information
Patient Gender*
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient E-Mail*
example@example.com
Patient Height (cm's)*
Patient Weight (kg's)*
Reason for seeing the doctor:*
Patient Medical History
Please list any drug allergies
AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications
Healthy & Unhealthy Habits
Never1-2 days3-4 days5+ days
I have a loose dietI have a strict dietI don't have a diet plan
I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Signature
Should be Empty:

General Patient Information