MEDICAL HISTORY FORM

Fill out the form below or download a pdf HERE. Please complete several days prior to your first appointment.

Name Occupation
Birthdate Employer
Height Currently working?
Weight Faith Tradition
Marital Status Single Married Divorced Widowed Separated
Referred By
PAST MEDICAL HISTORY
Primary Care Physician
Full Name
Last Visit
Address
PCP Phone
Please check any of the conditions listed below which you have had:
Asthma High Blood Pressure Stomach Ulcer
Emphysema Heart Attack Diabetes
Pulmonary Embolism Stroke Hepatitis
Venous Blood Clot Formation Thyroid Disease Depression
Neurological Problems Kidney Disease Mental Illness
Cirrhosis Prostate Cancer Sleep Apnea
Please list any other medical problems for which you are currently under treatment:
Condition Treating Physician Date last seen by doctor
Please list every operation that you have had, including the year, surgeon and hospital if possible:
Surgery Year Surgeon Hospital
Please list all of your current medications, including dosage:
Medication Dosage (mg) How Often Prescribed By
Allergies to medications:
Medication Type of Reaction
Are you allergic to latex? Yes No
Habits
Do you smoke? Yes No Packs per day Years smoking
Have you ever smoked? Yes No Year you quit Years smoked
Do you drink alcohol? Yes No Drinks per day 2 3-4 5-6 >6
FAMILY HISTORY
Do/did any of your brothers, sisters or parents have any of the following:
Rheumatoid Arthritis Heart Attack
Other Joint Problems Cancer
Bleeding Problems Diabetes
Anesthesia Problems Stroke
Mental Illness Thyroid Disease
SOCIAL HISTORY
How many people live in your household (including you)?
How are they related to you?
Do you have stairs at home? Yes No Inside Outside

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