Medical History Form

Medical History
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical History
List your current and past medical conditions, and year of diagnosis.
Surgical History
List the types and dates of surgeries you have had.
Medications (name, strength, frequency)
List medications prescribed and over-the-counter currently taking.
Allergies
List medication allergies/intolerances, and specific associated symptoms(s).
Smoking History
Have you ever smoked, and if so, how much and for how long?
Alcohol Use
Do you consume alcoholic beverages, and if so, how much?
List any family members with these conditions:
Please indicate any recent symptoms you have experienced:

Other
If you are being seen for diabetes, please complete the following questions. Otherwise, scroll to the bottom and click SUBMIT.
How many years have you been diagnosed with diabetes?
How many times per day do you test your sugars?
If you do not have your glucose meter or records, please list typical glucose levels:
How often do you exercise?
Have you attended diabetes classes or received nutritional counseling?
Do you have damage to your eyes from diabetes, and when was your last eye exam?
Do you have pain, burning, tingling or numbness in your feet, and when was the last time you had a foot exam?
Do you have pain in the legs when you walk, and if so, how long can you walk before experiencing pain?
Do you have a history of heart attack, heart failure, or stroke? If so, what year were you diagnosed?
When was your last dental examination?
List what you typically have at each meal/snack:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Medical History

If you are being seen for diabetes, please complete the following questions. Otherwise, scroll to the bottom and click SUBMIT.