MEDICAL HISTORY
Name:
*
Sex:
*
Male
Female
Email
*
Please check PAST and/or CURRENT Illnesses:
*
ADD/ADHD
Anemia
Anxiety
Arthritis
Asthma/Allergies
Atrial Fibrillation
Blood Clot
High Blood Pressure
Cancer
High Cholesterol
COPD
Diabetes
Depression
Emphysema
Erectile Dysfunction
Fibromyalgia
Gallstones
Gout
Heart Attack
Heartburn/Reflux
Kidney Disease
Liver Disease
Rheumatologic Disease
Seizures
Stroke
Substance Abuse
Have you ever had a Colonoscopy?
*
Yes
No
Date of last Colonoscopy:
*
Immunization Dates: (If not applicable, please type N/A.)
*
Current Medications: (Includes OTC)
*
Allergies: (Please list all that apply, such as medications, pollen, foods, etc.)
*
How often do you exercise?
*
Everyday
1 - 2 times per week
a few times per month
never
How often do you consume alcoholic beverages? (ie.: per day/month)
*
Recreational drug use?
*
Have you ever smoked?
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Yes
No
How many years?
*
How much? (i.e. cigarettes, packs)
*
Are you still smoking?
*
Yes
No
Quit Date:
*
Please list Surgical History & Date performed:
*
Family History: (Check if anyone in your family has ever had the following.)
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No
Yes
Relationship
Diabetes
High Blood Pressure
Anemia
Hear Disease
Cancer & Type
Bleeding Disorder
Stroke
Migraine Headaches
Obesity
Thyroid Disease
Elevated Cholesterol
Kidney Disorder
Gout
Asthma
Arthritis
Mental Illness
Allergies
Other
Have you ever been pregnant?
*
Yes
No
Number of pregnancies:
*
Number of live births:
*
Number of living children:
*
Pregnancy Complications?
*
Date of last Pap Smear:
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Abnormal Pap Tests?
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Yes
No
Date of last Mammogram:
*
Do you use Contraception?
*
Yes
No
Type of Contraception used?
*
SUBMIT
Should be Empty: