Medical History Form

Patient Name: *

Email: *

Date of Birth: *

Medication List:

Are you on any blood thinners?:

YesNo

Allergies(Medication or Other):

Surgery History:

Medication History:

Do you drink coffee daily?:

YesNo

If Yes:

RegularDecaf

Do you drink tea daily?:

YesNo

If Yes:

RegularDecaf

Do you smoke?:

YesNo

How much do you smoke?:

How long have you smoked?:

Do you drink alcohol?:

YesNo

How often?:

Mark an “X” on any condition in your immediate family:

DiabetesHigh Blood PressureStrokeKidney StonesKidney FailureCancerOther
(Cancer Type?)

Specify Other Condition/s:

Mark an “X” if you currently have a significant
and persisting problem or have had in the past:

General

FeverWeight Loss (>10 pounds/in 6 months)

Eyes

CataractsVision LossDouble VisionGlaucoma

Neurology

Dizzy SpellsFrequent HeadachesSeizuresStrokeTIATremors

Gastrointestinal

UlcersAbdominal PainsNauseaHeartburnColon CancerBlood in Stool

Cardiovascular

Chest PainHeart AttackIrregular Heart BeatHigh Blood PressureFeel Heart Racing

Skin

Skin CancerMelanomaPersistent RashYellow JaundiceBreast Cancer

Musculoskeletal

Back PainNeck PainArthritisUse Wheelchair

ENT

Hearing LossSore ThroatSinus Infection

Respiratory

Shortness of BreathAsthmaLung CancerEmphysema/COPDRequire Oxygen

Blood/Lymphatic

AnemicSwollen GlandsBleed/Bruise EasilyBlood Transfusion

Psychiatric

Depression Treatment

Gynecologic

HysterectomyAbnormal PAPCervical CancerVaginal BleedingVaginal Discharge