360infusioncenter.com - Full Patient Medical History Form

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.

Gender

MaleFemaleOther

Please check YES or NO if you HAVE BEEN DIAGNOSED with ANY of these conditions in your past:

Common Conditions

	Yes	No
Hypertension
Type 1 Diabetes
Type 2 Diabetes
High Cholesterol
Osteoporosis
Depression

Cancer

Have you ever been diagnosed with Cancer?

YesNo

Type:

Hearing/Eyes/ENT

	Yes	No
Glaucoma
Macular Degeneration
Diabetic Retinopathy
Hearing Loss
Ear Infections
Sinusitis Chronic

Respiratory

	Yes	No
Asthma
COPD
Chronic Bronchitis
Interstitial lung disease
Emphysema
Pulmonary Embolism
Obstructive Sleep Apnea
Tuberculosis exposure

Cardiology

	Yes	No
Atrial Fibrillation
Angina
CHF (Congestive Heart Failure)
Heart Attack (myocardial infarction)
Aortic Valve Disorder
Mitral Valve Disorder

Pacemaker :

YesNo

Date of Placement

Neurology

	Yes	No
Alzheimer’s Disease
Parkinson’s Disease
Seizures
Gail Instability with falls
Peripheral Neuropathy
TIAs
Migraine Headaches
Multiple Sclerosis
Trigeminal Neuralgia

Stroke:

YesNo

Area Affected:

Psychiatric

	Yes	No
Alcoholism
ADD/ADHD
Bipolar Disorder
Bulimia
Drug Abuse

Common Conditions

	Yes	No
Hypothyroidism
Coronary Artery Disease
Congestive Heart Failure
COPD
Osteoarthritis (generalized)
Anxiety

Gastrointestinal

	Yes	No
Acid Reflux
Barrett’s Esophagus
Peptic Ulcer Disease
Ulcerative Colitis
Irritable bowel syndrome
Diverticulosis
H/O Colon Cancer

Urinary/Renal

	Yes	No
Polycystic kidney disease
Nephrolithiasis
Urinary Incontinence
History of UTI’s

Musculoskeletal

	Yes	No
Arthritis
Osteopenia/Osteoporosis
Lumbar disc disease
Restless Leg Syndrome
Rotator cuff syndrome
Sciatica
Spinal Stenosis of: Cervical Spine
Spinal Stenosis of: Lumbar Spine
H/O compression - Fractures

Rheumatology

	Yes	No
Gouty Arthritis
Fibromyalgia
SLE
Rheumatoid Arthritis
Lupus Erythematosus

Hematology

	Yes	No
B-12 deficiency anemia
Iron deficiency anemia
Myelodysplastic Syndrome
Anemia

Endocrine

	Yes	No
Grave’s Disease
Hyperthyroidism
Hypothyroidism
Thyroid Nodule

Skin

	Yes	No
Basal Cell Carcinoma
Squamous Cell Carcinoma
Melanoma
Psoriasis
Rosacea

	Yes	No
Bladder suspension surgery
Fibrocystic breast disease
Hysterectomy
H/O of cervical or endometrial cancer
Polycystic ovarian disease
Uterine Prolapse

	Yes	No
Erectile Dysfunction
Prostate Enlargement
Hypogonadism
H/O of prostate cancer
Urological implant

	Yes	No
Aortic aneurysm repair
Aortic Valve Repair
Appendix removal (Appendectomy)
Bariatric surgery
Carpal tunnel release
Cataract surgery : Right
Cataract surgery : Left
Colon resection (Colectomy)
Coronary artery - Bypass surgery
Gallbladder removal (Cholecystectomy)
Gastric Bypass surgery
Hemorrhoid removal (Hemorrhoidectomy)
Hernia Repair : Femoral
Hernia Repair : Inguinal
Kidney Removal: (Nephrectomy) Right
Kidney Removal: (Nephrectomy) Left
Mitral valve replacement
Parathyroid removal (Parathyroidectomy)
Pacemaker placement
Polyp Removal (Polypectomy)
Septum and nose repair
Thyroid removal (Thyroidectomy)
Tonsillectomy
Varicose vein surgery

	Yes	No
Breast Implants
Breast reduction
C-Section
Endometrial biopsy
Hysterectomy : Partial
Hysterectomy : Complete
Lumpectomy : Right Breast
Lumpectomy : Left Breast
Mastectomy : Right Breast
Mastectomy : Left Breast

	Yes	No
Left Hip
Right Hip
Left Knee
Right Knee
Left Shoulder
Right Shoulder
Right Elbow
Left Elbow

MEDICAL HISTORY

MEDICAL HISTORY PART II

SURGICAL HISTORY

	Yes	No
Bone Marrow
Liver
Skin