Medical History
Name
*
First Name
Last Name
Date of Birth
*
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Month
/
Day
Year
Date
Medical History
List your current and past medical conditions, and year of diagnosis.
Surgical History
List the types and dates of surgeries you have had.
Medications (name, strength, frequency)
List medications prescribed and over-the-counter currently taking.
Allergies
List medication allergies/intolerances, and specific associated symptoms(s).
Smoking History
Have you ever smoked, and if so, how much and for how long?
Alcohol Use
Do you consume alcoholic beverages, and if so, how much?
List any family members with these conditions:
Please indicate any recent symptoms you have experienced:
Headaches
Dizziness/lightheadedness
Change in vision
Hearing loss
Fever
Cough
Shortness of breath
Chest pains
Palpitations
Heart murmur
Nausea/vomiting
Abdominal pain
Loss of appetite
Weight loss
Weight gain
Constipation
Diarrhea
Bloody or black stools
Excessive sweating
Swollen ankles
Frequent thirst
Frequent urination
Painful urination
Bloody urine
Joint pains/swelling
Muscle aches
Muscle weakness
Skin rash
Unusual fatigue
Decreased sex drive
Difficulty with erections (male)
Irregular periods (female)
Increased hair loss
Increased hair growth
Increased sensitivity to heat
Increased sensitivity to cold
Unusual anxiety
Other
If you are being seen for diabetes, please complete the following questions. Otherwise, scroll to the bottom and click SUBMIT.
How many years have you been diagnosed with diabetes?
How many times per day do you test your sugars?
If you do not have your glucose meter or records, please list typical glucose levels:
How often do you exercise?
Have you attended diabetes classes or received nutritional counseling?
Yes
No
Do you have damage to your eyes from diabetes, and when was your last eye exam?
Do you have pain, burning, tingling or numbness in your feet, and when was the last time you had a foot exam?
Do you have pain in the legs when you walk, and if so, how long can you walk before experiencing pain?
Do you have a history of heart attack, heart failure, or stroke? If so, what year were you diagnosed?
When was your last dental examination?
List what you typically have at each meal/snack:
Date
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Month
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Day
Year
Date
Submit
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