Medical History Questionnaire
NAME: ______________________________
Please list ALL surgical procedures you have had in the past:
Surgery:
Date: _________
Surgery: ________________________ Date: _________
Surgery: ________________________ Date: _________
Have YOU had or are being treated for (check all that apply):
 Cancer
 Emphysema/COPD
 Pacemaker
 Asthma
 Heart Attack
 Bronchitis
 Angina/Chest pain
 Tuberculosis
 Congestive Heart Failure
 Multiple Sclerosis
 Stroke
 Parkinson’s Disease
 Blood clots
 Seizures/Epilepsy
 Anemia
 Arthritis
 High blood pressure
 Rheumatoid Arthritis
 Diabetes
 Osteoporosis
 Thyroid disease
 Kidney disease
DATE:
Surgery: ________________
Surgery: ________________
Surgery:
/
/
Date: __________
Date: __________
Date: __________
 Liver disease
 Lupus
 Hepatitis
 Sexually transmitted disease/HIV
 GI problems/bleeding
 Ulcers/Stomach problems
 Headaches
 Bone or Joint infection
 Eye problem/infection
 Chemical dependency (i.e. alcoholism/drugs)
 Other: ________________
Has anyone in your immediate FAMILY (parents, brothers, sisters) EVER been diagnosed with (check all that apply):
 Cancer
 Diabetes
 Tuberculosis
 Heart disease
 Stroke
 Thyroid disease
 High blood pressure
 Depression
 Blood clots
In the past 3 months have you had or are experiencing (check all that apply):
 Change in your health
 Fever/chills/sweats
 Dizziness/vertigo/balance problems
 Difficulty swallowing
 Unexplained weight gain/loss
 Urinary tract infection
 Changes in bladder function
 Changes in appetite
 Hearing/visual disturbances
 Upper respiratory infection
 Numbness/tingling
 Shortness of breath
 Nausea/vomiting
 Changes in bowel
 Difficulty sleeping
Please list any medications that you are currently taking (include pills, injections, and/or skin patches):
 Please see attached list
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_______________________________________
Allergies (Please list any medication(s) you are allergic to below):
_________________________________________________________________________________________________________
_________________________________________________________________
___________________________________________________________________
Signature (THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE)
Revised 02/01/2013
____________
DATE