PATIENT MEDICAL HISTORY
Patient’s Name: ____________________________________________ Date: _______/_______/_______
Height: ____________ Weight: ______________ Blood Pressure: ____________ Pulse: ___________
Medication Allergies: ____________________________________________________________________
Are you allergic to Internal or External Iodine/Betadine?
Medication Name / Dosage:
Yes ________
Prescribing Dr.:
No ________
Reason for Taking:
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Pharmacy:__________________________
City:_________________
Phone:____________________
PLEASE CHECK ANY ILLNESSES THAT YOU NOW HAVE OR HAVE PREVIOUSLY HAD:
□ High Blood Pressure
□ Heart Disease / Problems
□ Heart Attack
□ Stroke
□ Poor Circulation
□ Vein Problems
□ Anemia
□ Blood Disorders
□ Diabetes
□ Kidney Disorders
□ Pneumonia
□ Emphysema
□ Asthma
□ Peptic Ulcer Disease
□ Reflux Disease
□ Tuberculosis
□ Hepatitis □A □B □C
□ HIV / AIDS
□ Rheumatic Fever
□ Bladder Infections
□ Joint Replacement: What Joint? ______________________
□ Lupus
□ Arthritis
□ Blood Clot
□ Epilepsy
□ Cancer: Where? __________________________________
□ Hay Fever / Allergies
□ Mental Illness
□ Seizures
□ Other ___________________________________________
Have you ever suffered any complications from past surgeries or from general anesthesia?
□ Yes
□ No
Past Surgeries and Dates: ___________________________________________________________________________________
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FAMILY MEDICAL HISTORY
Please identify any medical problems your BLOOD RELATIVES have or have had in the past:
□ Birth Defects
□ Asthma
□ Bone / Joint Disorders
□ Muscle Disorders
□ Skin Disease
□ Eye / Ear Disorders
□ Cancer
□ Diabetes
□ Thyroid Disease
□ Anemia / Blood Disorders
□ High Blood Pressure
□ Kidney Disease / Problems
□ Rheumatic Fever
□ Tuberculosis
□ Seizures / Convulsions
□ HIV / AIDS
□ Other_____________________________
Social History
Do you smoke?
Yes _______
No ________
Do you drink Alcohol? Yes ______ No _______
If yes, how many packs per day? _________________
If yes, how much per day? _______ Per week? ______