Medical History Form

    Date:
    Patient Name:
    Today’s Date:
    Reason for today visit:
    Age:
    Height:
    Weight:
    List all medications which you are currently taking (Including aspirin and and non-prescription):
    List all surgeries that you have had (Include Plastic Surgery):
    Date:
    Surgery:
    Do you take herbal supplements or vitamins (especially Gingko, Ginger, Garlic, St. John’s Wort, C, E, Fish oils)?:
    List all drug allergies (including latex):
    Are you a smoker?
    YESNO
    If YES; How long?
    Do you drink alcohol?
    YESNO
    If YES; How much?:
    Have you had the following?
    Chest Pain:
    YESNO
    Breast Disease:
    YESNO
    Seizures:
    YESNO
    Heart Murmur:
    YESNO
    Thyroid Disorder:
    YESNO
    Problems with Scarring:
    YESNO
    Hight Blood Pressure:
    YESNO
    Hepatitis C:
    YESNO
    Emotional Problems:
    YESNO
    Anemia Diabetes:
    YESNO
    Kidney Problems:
    YESNO
    HIV:
    YESNO
    Cancer:
    YESNO
    Asthma:
    YESNO
    Dryness of Eyes:
    YESNO
    Bleeding Disorders:
    YESNO

      Expected Operation Date:

      Patient Name:

      Today’s Date:

      Reason for today visit:

      Age:

      Height:

      Weight:

      List all medications which you are currently taking (Including aspirin and and non-prescription):

      List all surgeries that you have had (Include Plastic Surgery):

      Date:

      Surgery:

      Do you take herbal supplements or vitamins (especially Gingko, Ginger, Garlic, St. John’s Wort, C, E, Fish oils)?:

      List all drug allergies (including latex):

      Are you a smoker?
      YESNO

      If YES; How long?

      Do you drink alcohol?
      YESNO

      If YES; How much?:

      Have you had the following?

      Chest Pain:
      YESNO
      Breast Disease:
      YESNO
      Seizures:
      YESNO
      Heart Murmur:
      YESNO
      Thyroid Disorder:
      YESNO
      Problems with Scarring:
      YESNO
      Hight Blood Pressure:
      YESNO
      Hepatitis C:
      YESNO
      Emotional Problems:
      YESNO
      Anemia Diabetes:
      YESNO
      Kidney Problems:
      YESNO
      HIV:
      YESNO
      Cancer:
      YESNO
      Asthma:
      YESNO
      Dryness of Eyes:
      YESNO
      Bleeding Disorders:
      YESNO

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