Complete Medical History

COMPLETE MEDICAL HISTORY

PATIENT’S NAME:______DOB: _____/_____/_____

PATIENT’S HEIGHT: ______WEIGHT:______

MEDICAL PROVIDERS:

PRIMARY CARE PHYSICIAN: ______

REFERRING PHYSICIAN: ______

MEDICAL CONDITIONS
(Check conditions you currently have or have had in the past year)
___ Alcoholism / ___ Emphysema / ___ Pacemaker / ___ Other
___ Alzheimer’s/Dementia / ___ Eating Disorders / ___ Multiple Sclerosis / ___ Vascular Problems
___ Anemia/Blood Disorder / ___ Environmental Allergies / ___ Pet Allergies / Circle:
___ Anxiety / ___ Epilepsy/Seizures / ___ Pneumonia / Fibromyalgia
___ Arthritis / ___ GERD/Reflux / ___ Prostate Problem / Back Problems
___ Asthma / ___ Headaches / ___ Psychiatric Care (current) / Eating Disorders
___ Blood Problems / ___ Heart Disease / ___ Rheumatic Fever
___ Cancer / ___ High Blood Pressure / ___ Stroke
___ Chemical Dependency / ___ High Cholesterol / ___ Thyroid Problems
___ Chronic Bronchi / ___ Kidney Problems / ___ Tonsilitis
___ COPD / ___ Hepatitis / ___ Sinus Problems
___ Depression / ___ Liver Problems / ___ Tuberculosis
___ Diabetes-
Insulin, Diet, Pill Controlled / ___ Migraine / ___ Ulcers
SURGERIES and YEAR
___ Aneurysm/Repair Type ______/ ___ Carpal Tunnel / Hand / ___ Orthopedic (Hip, Shoulder, Knee ) Type:
Location:
___ Angioplasty/Stent______/ ___ Cataract / Eye / ___ Pacemaker / AICD Implant
___ Appendectomy / ___ Colon / StomachSurgery / ___ Thyroid Surgery
___ Back Surgery Location:______
Type: / ___ Gall Bladder / ___ Tonsils / Adenoids / UPPP (sleep surgery)
___ Bowel Surgery / ___ Gynecological Surgery / ___ Vasectomy
___ C-Section
How Many: / ___ Hernia Repair / ___ Vascular Surgery (Circulation) Type:
Location:
___ Cancer Surgery:
Type______/ ___ Kidney Surgery / ___ Other:
___ Cardiac (Heart / Valve) Surgery / ___ Lung Biopsy/ Surgery
Location:
___ Carotid Surgery
Location: / ___ Nasal Surgery

PATIENT’S NAME: DOB: / /

DRUG ALLERGIES AND REACTIONS:______
______
DO YOU HAVE A LATEX ALLERGY? YES OR NO
Reading Ability: Y_ N _ OCCUPATION:
CURRENT MEDICATION LIST (Include Dosage and Frequency)
1. / 8.
2. / 9.
3. / 10.
4. / 11.
5. / 12.
6. / 13.
7. / 14.
HEALTH HABITS: Check which you use and how much you use
____ Caffeine: circle: coffee soda teas energy
drink / How Much How Often:
____ Tobacco Type: ______Years Smoked:______/ Pack Per Day: ___ How Long ____ Quit: Y OR N Quit date:
____ Street Drugs Type: / How Much How Often:
____ Alcohol Type: / None____ Rarely____ Routinely____ Recovering Alcoholic______
OCCUPATIONAL HABITS: Check if you have been exposed to
____ Asbestos Exposure / ____ Hazardous Waste
____ Diesel Fuels / ____ Other
____ Tuberculosis Exposure
FAMILY HISTORY
_____Adopted Mother Father Sibling Grandparent OTHER
Obstructive Sleep Apnea
Diabetes
Thyroid Problems
Blood Disorders (Anemia, Bleeding Disorders)
High Cholesterol
COPD/Respiratory
Asthma
Strokes/Mini Strokes
Heart Attack / Surgery
Hypertension/ Vascular
Allergy (Seasonal, Environmental)
Sinus Problems
Alzheimer’s
Cancer/ Type
Reproductive Problems
Kidney Disease/Dialysis
Liver Problems
Stomach Problems
Arthritis/ Bone Joint
Other (Please write in)