Medical History Form
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Previous Doctor
Reason for Change
Dentist
Local Pharmacy
Chief Complaint
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Family and Past Medical History
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Osteoporosis
Stroke
Glaucoma
Epilepsy
Kidney Disease
Thyroid Disease
Mental Illness
Bleeding Disorder
Other
Check the symptoms that you' re currently experiencing:
Chest pain
Shortness of Breath
Headache
Heart Palpitations
Heart Murmur
Dizziness/ Fainting
Asthma
Allergies
Bronchitis
Pneumonia
Weight gain
Weight loss
Gastritis
Gout
Incontinence
Urinary infections
Anxiety/ Depression
Sexual/ Menstrual dysfunction
Other
WOMEN ONLY: Are you Pregnant?
Yes
No
Not Sure
WOMEN ONLY: Planning Pregnancy?
Yes
No
Are you currently taking any medication?
*
Yes
No
Please list them.
Do you have any medication allergies?
*
Yes
No
Not Sure
Please list them.
Have you ever been hospitalized?
*
Yes
No
Not Sure
Please list the date and reason for hospitalization.
Have you had any surgeries?
*
Yes
No
Not Sure
Please list the date and reason for surgery.
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Next
Habits
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Submit
Should be Empty: