Medical History
Name
First Name
Last Name
Reason for visit
Are you allergic to any medication? If yes, List:
List all medications you are currently taking:
Height and Weight
-
H
W
Do you have now, or have you ever had diseases or conditions of: (please check if so)
Lungs
Bronchitis
Emphysema
Asthma
Chronic Cough
Morning Cough
Vascular:
High Blood Pressure
Chest Pain
Heart Attack
Heart Murmur
Irregular Heartbeat
Pacemaker
Phlebitis
Other Systemic:
Diabetes
Thyroid
Kidney
Bladder
Stomach
Bowel
Hepatitis or Yellow Skin
Glaucoma
Arthritis
Convulsions, Epilepsy or Seizures
Fainting
Do you drink alcohol?
Yes
No
If YES how many drinks per day?
Do you use IV drugs?
Yes
No
If YES, what do you use? and How much?
Have you had or have you been exposed to HIV (AIDS)?
Yes
No
Have you ever had dental anesthesia (novacaine)?
Yes
No
Any bad reactions to question above?
When you are exposed to the sun, do you:
Tan only
Tan and Burn
Burn
Have you ever had skin cancer?
Yes
No
Has anyone in your family had skin cancer? If yes, who?
If you have any specific skin disease please list below:
List any other disease or condition we should know about:
List any surgical procedure you have had in the last 6 months:
Do you smoke
Yes
No
If you smoke, How much?
Do you bleed easy?
Yes
No
(Women) Are you pregnant?
Yes
No
Trying to become pregnant
Do you have artificial joints?
Yes
No
What is your occupation?
What are your hobbies?
Submit
Should be Empty: