PAST MEDICAL HISTORY FORM - Electronic Version

Please list ALL current medication(s) AND supplements:

	Current Medication (One medication per line)	Reason for taking
1
2
3
4
5
6
7
8

Current & Past Medical History*

No ongoing medical problemsHypertension (high blood pressure)Past myocardial infarction (Heart Attack)AsthmaUlcer disease/GERDKidney diseaseHepatitis or liver diseaseRheumatologic joint diseaseHIV/AIDSThyroid Disorder
Bleeding or Clotting Disorders:*
If yes, please specify:*
Bowel Disease:*
If yes, please specify:
Diabetes*

YesNoYes, I am insulin dependent
Sleep Apnea*

YesNoYes, 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 depressionAnxietyNo past psychological history
Other psychological - please explain:
Latex Allergy:*
Medication Allergies:*

Medication Allergies

	Medication Name (One medication per line)	Reaction
1
2
3
4
5
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8

Please list all past surgeries:

	Surgery Description (One procedure per line)	Date of Procedure
1
2
3
4
5
6
7
8

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*

MonthDayYear
Date
Should be Empty: