Patient Medical History Form

General Patient Information
Browse Files
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Patient Name*
First NameLast Name
Patient Gender*
Patient Birth Date*
MonthDayYear
Patient Height (cm's)*
Patient Weight (kg's)*
Patient E-Mail*
Reason for seeing the doctor:*

Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)
AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications

Healthy & Unhealthy Habits
Exercise
Never1-2 days3-4 days5+ days
Eating following a diet
I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption
I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption
I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?
No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Should be Empty: