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

    Anämie Diabetes:
    JANEIN

    Anemia Diabetes:
    YESNO

    HIV:
    YESNO

    Cancer:
    YESNO

    Asthma:
    YESNO

    Dryness of Eyes:
    YESNO

    Bleeding Disorders:
    YESNO

      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?
      JANEIN

      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