PAST MEDICAL HISTORY FORM - Electronic Version

Please list ALL current medication(s) AND supplements:

Current Medication
(One medication per line)

Reason for taking

Current & Past Medical History *

No ongoing medical problems Hypertension (high blood pressure) Past myocardial infarction (Heart Attack) Asthma Ulcer disease/GERD Kidney disease Hepatitis or liver disease Rheumatologic joint disease HIV/AIDS Thyroid Disorder
Bleeding or Clotting Disorders: *
If yes, please specify: *
Bowel Disease: *
If yes, please specify:
Diabetes *

Yes No Yes, I am insulin dependent
Sleep Apnea *

Yes No Yes, I use a CPAP
Cancer: *
If yes, please specify:
Previous MRSA/Staph or other infections: *
If yes, please specify location
Family history of malignant hyperthermia *
If yes, which family member
Other medical history - Please explain:
Since last September 1st, have you received: (Check those that apply) *

Influenza (flu) vaccine? Pneumococcal (Pneumonia) vaccine? COVID-19 Vaccine?
Psychological History: *

Medical treatment for depression Anxiety No past psychological history
Other psychological - please explain:
Latex Allergy: *
Medication Allergies: *

Medication Allergies

Medication Name
(One medication per line)

Reaction

Please list all past surgeries:

Surgery Description
(One procedure per line)

Date of Procedure

Family History *

MOM

DAD

SISTER(s)

BROTHER(s)

MAT
GRMTH

MAT
GRFTH

PAT
GRMTH

PAT
GRFTH

Status:
A=Alive
D=Decd
U=Unk

Place a (X) next to those that apply

Osteoarthritis

Cancer

Diabetes

Stoke

Heart Attacks

Rheumatoid Arthritis

Bleeding Tendencies

Anesthetic problems or complications

Tobacco User *
How many packs per day do you smoke?
Other tobacco products? - Please specify:
Drug Use? (Specify type of drug):
Alcohol Use? *
How often do you have an alcoholic beverage?
Marital Status *
Number of Children
Hobbies
Current Occupation
Place of Employment
Job Status
Time with present employer
Primary Care Physician Name
Primary Care Physician Phone Number
Referring Physician Name
Referring Physician Phone Number
I agree that the Past Medical History information completed is correct to the best of my knowledge.
Patient/Guardian Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: