Past Medical Hx Form
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Patient Name: DOB: Allergy Information: Do you have any allergies to medication, testing dye or latex (as in gloves)? Name of Medication that you are allergic to: ____________________ Circle Reaction: Hives Difficulty Breathing or Swallowing Itching Swelling Rash ____________________ Circle Reaction: Hives Difficulty Breathing or Swallowing Itching Swelling Rash ____________________ Circle Reaction: Hives Difficulty Breathing or Swallowing Itching Swelling Rash ______________________________________________________________________________________ ______________________________________________________________________________________ Or if you have no allergies circle here: None Know Drug Allergies Family Medical History: Mother Father Sisters Brothers Children # Alive _______ _______ _______ _______ _______ _______ #Deceased _________ _________ _________ _________ _________ _________ Medical Problems/ Cause of Death ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Check if any family members have: ___Colon Cancer ___Colon Polyps/Tumors ___Ulcerative Colitis ___Crohn’s Disease ___Irritable Bowel ___Breast Cancer ___Ovarian Cancer ___Uterine Cancer ___Other type G.I. Cancer ___Other type of Cancer ___Diabetes ___Heart Trouble ___High Blood Pressure ___Stroke Your Medical History LIST ALL MEDICAL CONDTIONS YOU ARE BEING TREATED FOR/HAVE BEEN TREATED FOR:_________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Check if you have: _____Mitral or Aortic Valve Replacement _____Hip, Knee or Shoulder replacement _____Cardiac Stents _____Heart Pacemaker _____Implanted Defibrillator LIST ALL SURGERIES/ OPERATIONS YOU HAVE EVER HAD AND THE YEAR: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
