Medical History Form
Date of last visit
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Physician
Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have any of the following medical conditions:
1. Abnormal bleeding/Hemophilia
Yes
No
2. Diabetes
Yes
No
3. Hepatitis/Liver problems
Yes
No
4. Pneumonia
Yes
No
5. Anemia
Yes
No
6.Dizziness
Yes
No
7. Herpes
Yes
No
8. Prolonged Bleeding
Yes
No
9. Arthritis
Yes
No
10. Epilepsy
Yes
No
11. High Blood Pressure
Yes
No
12. Radiation/Chemotherapy
Yes
No
13. Asthma or Hayfever
Yes
No
14. Gastrointestinal Disorders
Yes
No
15. HIV / Aids
Yes
No
16. Rheumatic Fever
Yes
No
17. Bone Disorders
Yes
No
18. Heart Problems
Yes
No
19. Kidney problems
Yes
No
20. Tuberculosis
Yes
No
21. Congenital Heart Defect
Yes
No
22. Heart Murmur
Yes
No
23. Nervous Disorders
Yes
No
24. Tumor or Cancer
Yes
No
25. Are you pregnant?
Yes
No
26. Are there any medical conditions we have not discussed that you feel we should be aware of?
Yes
No
If yes, describe:
27. Have you ever been involved in a serious accident?
Yes
No
If yes, describe:
28. Are you aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
Yes
No
29. Are you often exhausted or fatigued
Yes
No
30. Are you experiencing frequent headaches
Yes
No
31. Are you a smoker, smoked previously or use smokeless tobacco
Yes
No
32. Are you currently taking any medications.
Yes
No
If yes, describe
Patient / Guardian’s Signature
Date
-
Month
-
Day
Year
Date
Doctor’s Signature
Date
-
Month
-
Day
Year
Date
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Should be Empty: