WhatClinic Patient Service Award

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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