Medical History Form

Medical History
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
What is your Gender?*

MaleFemale
Phone Number*

Area CodePhone Number
Check the conditions that apply to you now or previously*

ArthritisFracturesJoint ReplacementCancerHeart diseaseDiabetesHypertensionKidney DiseaseCataractsAnemiaStomach UlcersDepression/AnxietyEpilepsy/ SeizuresThyroid problemsStrokeMultiple SclerosisAcid refluxValley feverOther
Past surgeries/operations
Check the symptoms that you're currently experiencing:*

Weight gainWeight lossFatigue/weaknessFeverEye redness/painDry eyesDry mouthMouth/nose soresDifficulty swallowingChest painPalpitationsCoughShortness of BreathCoughing bloodNausea/VomitingAbdominal painChange in bowel habitsBlood in urinejoint pain/stiffnessjoint swellingrashhair lossnail changesEasy bruising tendencyHeadachescolor changes of hands/feet in the coldTingling/numbnessSleep problemsswollen glandsAnxiety/depressionOther
Does anyone in your family confirmed to have the following conditions?

OsteoarthritisRheumatoid arthritisSystemic lupusSjogren's syndromeSclerodermaOsteoporosisHip FracturesGoutAnkylosing spondylitisPsoriasisPsoriatic arthritisPolymyalgia rheumaticaTemporal arteritisVasculitisMuscle problemsEye inflammationUlcerative colitisCrohn's diseaseOther
Are you currently taking any medication?*

Yes -list belowNo
Do you have any medication allergies?*

YesNoNot Sure
Preferred pharmacy name and phone number
Current medications*
Do you use or do you have history of using tobacco?*
How often do you consume alcohol?*

DailyWeeklyOccasionallyNever
Do you use or do you have history of using illegal drugs?*
Do you use or have a history of using medical marijuana?*
Should be Empty: