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