MEDICAL HISTORY
Patient's Name
*
First Name
Last Name
Initial
Date of Birth
Please select a month
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Month
Please select a day
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31
Day
Please select a year
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1925
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1923
1922
1921
1920
Year
Select the appropriate answer. If you don't know the correct answer please write "don't know" on the line after the question
Physician's Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you under a physician's care?
*
Yes
No
When
*
Why
*
When was your last complete physical exam?
Are you taking any medication or substances?
*
Yes
No
If yes, please list medications
*
Do you routinely take health related substances? (Vitamins, herbal supplements, natural products)
*
Yes
No
Are you allergic to any medications or substances?
*
Yes
No
If yes, please list
*
Do you have any other allergies or hives?
*
Yes
No
Do you have any problems with penicillin, antibiotics, anesthetics or other medications?
*
Yes
No
Are you sensitive to any metals or latex?
*
Yes
No
Are you pregnant or suspect you may be?
*
Yes
No
Do you use any birth control medications?
*
Yes
No
Have you ever been treated for or been told you might have heart disease?
*
Yes
No
Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?
*
Yes
No
Have you ever had rheumatic fever?
*
Yes
No
Are you aware of any heart murmurs?
*
Yes
No
Do you have high or low blood pressure?
*
Yes
No
Your blood pressure is
*
High
Low
Have you ever had a serious illness or major surgery?
*
Yes
No
If so, explain
*
Have you ever had radiation treatment, chemo treatment for tumor, growth or other condition?
*
Yes
No
Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis?
*
Yes
No
Do you have inflammatory diseases, such as arthritis or rheumatism?
*
Yes
No
Do you have any artificial joints/prosthesis?
*
Yes
No
Do you have any blood disorders, such as anemia, leukemia, etc?
*
Yes
No
Have you ever bled excessively after being cut or injured?
*
Yes
No
Do you have any stomach problems?
*
Yes
No
Do you have any kidney problems?
*
Yes
No
Do you have any liver problems?
*
Yes
No
Are you diabetic?
*
Yes
No
Do you have fainting or dizzy spells?
*
Yes
No
Do you have asthma?
*
Yes
No
Do you have epilepsy or seizure disorders?
*
Yes
No
Do you or have you had venereal or any sexually transmitted disease?
*
Yes
No
Have you tested HIV positive?
*
Yes
No
Do you have AIDS?
*
Yes
No
Have you had or do you test positive for hepatitis?
*
Yes
No
Do you or have you had T.B.?
*
Yes
No
Do you smoke, chew, use snuff or any other forms of tobacco?
*
Yes
No
Do you regularly consume more than one or two alcoholic beverages a day?
*
Yes
No
Do you habitually use controlled substances?
*
Yes
No
Have you had psychiatric treatment?
*
Yes
No
Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?
*
Yes
No
Do you have any disease condition, or problem not listed?
*
Yes
No
If so, explain
*
Is there anything else we should know about your health that we have not covered in this form?
Would you like to speak to the Doctor privately about any problem?
*
Yes
No
I certify that the above information is complete and accurate
Patient's / Guardian's Signature
*
Patient's / Guardian's Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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