Professional Medical History Template

Patient Medical History

Full Name

Joseph C Sanders

Address

2649 Camden Place

Myrtle Beach, South Carolina(SC), 29577

United States

Date of Birth

6 February 1970

E-mail

marilyne1976@yahoo.com

Phone Number

(843) 222-5371

Medical History Questions

1) Has you doctor ever said your blood pressure was too high or too low?

Yes

Please provide details

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2) Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?

Yes

Please provide details

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3) Has your doctor ever told you that your cholesterol was too high?

Yes

Please provide details

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4) Have you (or a family member) ever been told that you have diabetes?

Yes

Please provide details

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5) Do you have any injuries or orthopedic problems (back, knees, etc)?

Yes

Please provide details

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6) Do you have stiff or swollen joints?

Yes

Please provide details

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7) Do you have tension or soreness in any area?

Yes

Please provide details

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8) Are you taking any prescribed medications or dietary supplementation?

Yes

Please provide details

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9) Do you ever have problems sleeping?

Yes

10) Are you pregnant or post-partum (< 6 weeks)?

11) Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Yes

Please provide details

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12) Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?

Yes

Please provide details

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About this template

Every cardiologist has to know the medical history of their patient's unquestionable. If you want to identify your patient's diagnosis, this Medical History Record PDF template is there to help you in order to know the patient's case and previous condition.
You may collect the patient's data with this Medical History Record PDF template which allows you to ask medical questions about the cardiovascular problems to your customer. Also, you can collect personal information. You may know more about the medical background of your customer by using this Medical History Record PDF. In addition, you can create a Medical History Record PDF template with HIPAA Compliant.

Categories

Details

3,824 Clone

Created by

Jotform

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