Medical History
Patient Form
Patient Details
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Weight (kg)
*
Height (cm)
*
Gender
*
Female
Male
Next of Kin Details (if applicable)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Medical Conditions
Check the illness that you currently have or you had before :
AIDS or HIV+
Anemia
Asthma
Arthritis
Back Problems
Bladder Infection
Bleeding Tendency
Blood Clots
Bronchitis
Cancer
Colitis
Congenital Heart
Diabetes
Epilepsy
Fainting Spells
Goiter
Hay Fever
Hearth Attack
Hepatitis
High Blood Pressure
Kidney Disease
Migraine
Nervous Breakdown
Pacemaker
Pain in the Chest
Palpitations
Pneumonia
Rheumatic Hearth
Shortness of Breath
Stomach Ulcers
Stroke
Thyroid Disease
Tuberculosis
Other
Check the conditions that apply to you or to any members of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Bleeding Tendency
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Do you regularly smoke? (If yes, how much?)
Yes
No
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Have you recently had chest x-ray? (If yes, when?)
Yes
No
Any metal implants/devices (If yes, list?)
No
Other
Do you wear spectacles?
Yes
No
Do you wear contact lenses?
Yes
No
Do you wear dentures?
Yes
No
Do you regulary drink 6 or more cups of coffee per day?
Yes
No
Have you recently had a cold or flu? (If yes, when?)
Yes
No
Please list any medications (presription or over-the-counter) that you have taken within the last month.
Are you presently taking any medications? (If yes, list?)
*
Yes
No
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Do you have any medication allergies? (If yes, list all drug allergies and type of action)
*
Yes
No
Not sure
Check the allergies that you currently have:
Latex Allergies
Environmental
Tape Allergies
Drug Allergies
Food Allergies
If you have any allergies above, give details
Past Surgeries
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type
Have you had complications or bad reactions to anesthesia ? (If yes, List)
Yes
No
Have you ever had a blood transfusion ? (If yes, when?)
No
Other
Have you had a significant weight change in the last year? (If yes, please give details)
Yes
No
Do you have frequently bleeding gums ?
Yes
No
Have you ever bled excessively from a tooth extraction ?
Yes
No
Do you bleed excessively from a laceration ?
Yes
No
Do you have nose bleeds (If yes, how often?)
Yes
No
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Women Only
Is there any chance you may be pregnant ?
Yes
No
Number of Pregnancies
Number of Children
Are you still having regular menstrual periods ? (If yes, date of last menstrual period)
No
Other
Date of last mammogram
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Result
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Do you have or have you had Sleep Apnea ? Please consider the following symptoms of sleep apnea
I am frequently tired upon waking and throughout the day
Yes
No
I have trouble staying asleep at night
Yes
No
I have been told that I snore or stop breathing during sleep
Yes
No
I wake up throughout the night or constantly turn from side to side
Yes
No
I have been told that my legs or arms jerk while I’m sleeping
Yes
No
I make abrupt snorting noises during sleep
Yes
No
I feel tired or fall asleep during the day
Yes
No
Do you have or have you had Deep Vein Thrombosis or Pulmonary Embolus ? any past or present history of any of the following
Past History of Blood Clots
Yes
No
Family History of Blood Clots
Yes
No
Birth Control Pills
Yes
No
Swollen Legs
Yes
No
History of Cancer
Yes
No
Large Dose Vitamins
Yes
No
Varicose Veins
Yes
No
Past Illnesses of the Heart, Liver, Lung, or Gastrointestinal Tract
Yes
No
Signature
DateTime
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