PAST MEDICAL HISTORY

Name:       Date:   Email:  

Please answer ALL questions for appropriate medical treatment.

Please list ALL current medication(s) & supplements:
   Current Med:    Reason For Taking:
   Current Med:    Reason For Taking:
   Current Med:    Reason For Taking:
   Current Med:    Reason For Taking:

Current & Past Medical History:
        Hypertension (high blood pressure)
        Past myocardial infarction (heart attack)
        Bleeding or Clotting Disorders - If yes, please specify:  
        Diabetes  (Insulin Dependent: Yes No )
        Lung disease - If yes, please specify  
        Asthma
        Sleep Apnea  If so, do you use CPAP?  
        Ulcer disease/GERD
        Cancer  -  If yes, please specify  
        Bowel disease  - If yes, please specify  
        Kidney disease
        Hepatitis or liver disease
        Previous MRSA/Staph or other infections-  If yes, please specify location  
        Rheumatologic joint disease
        HIV/AIDS
        Thyroid Disorder
        Headaches  -  If yes, please specify type:  
        Other  
        No ongoing medical problems

Since last September 1st, have you received:
      Influenza (flu) vaccine?  Yes    No 
      Pneumococcal (pneumonia) vaccine?  Yes    No 

Psychological History:
        Medical treatment for depression
        Anxiety
        No past psychological history
        Other  

Allergies:             Yes    No  (If Yes Please List Below)
      Latex Allergy:  Yes    No 
          Medication Allergies:    Reaction:
          Medication Allergies:    Reaction:
          Medication Allergies:    Reaction:
          Medication Allergies:    Reaction:


Please list all past surgeries:
   Surgery:    Date:
   Surgery:    Date:
   Surgery:    Date:
   Surgery:    Date:


Family History
MotherFatherSisterBrotherMaternal
Grandmother		Maternal
Grandfather		Paternal
Grandmother		Paternal
Grandfather
Status:
A=Alive
D=Deceased
U=Unknown
Osteoarthritis
Cancer
Diabetes
Stroke
Heart
Attacks
Rheumatoid
Arthritis
Bleeding
Tendencies
Anesthetic
problems or
complications

Other:

Habits

  Tobacco:  Yes  No    Packs per day:    Former smoker?
                Other tobacco products?  - Please Specify:
  Drug Use:  Yes  No    Specify type of drug:
  Alcohol:  Yes  No    How often do you have an alcoholic beverage?

Social History:
Marital Status:   Single  /  Married  /  Divorced  /  Separated  /  Widowed
Number of Children:
Hobbies:

Current Occupation:
    Place of Employment:
    Job title / position:
          Full Time
          Part Time
    Time with present employer:

Primary Care Physician Name:Phone:

Referring Physician Name:Phone:


I agree that the Past Medical History information completed is correct to the best of my knowledge.

Patient/Guardian Signature:Date: