Medical History Form

(to be filled up by patient)



Please put a Select on (Yes) or (No) for the diseases enumerated below. Do you have a history of:

Yes No Bleeding Problems (nose bleeds, gum bleeds, easy bruising, anemia )
Yes No Poor or abnormal healing ( wide scars, raised scars, large scars, keloids, slow healing)
Yes No Ophthalmologic (Eye Problems, cataract, glaucoma)
Yes No Ear Problems (Ear aches, abnormal discharge, decrease hearing)
Yes No Liver Problems (hepatitis A, B, C)
Yes No High Blood pressure
Yes No Heart Disease ( heart attack, chest pain, arrhythmia, irregular pulse, murmur, rheumatic fever)
Yes No Lung Disease (asthma, pneumonia, chronic bronchitis, pleurisy)
Yes No Hormonal Disease ( diabetes, thyroid problems, etc.)
Yes No Kidney, Bladder disease, prostate problems
Yes No Stomach disease (ulcers, heart burn)
Yes No Neurologic Disease (Stroke, seizure, fainting, epilepsy, meningitis, neuralgia, migraine)
Yes No Hay fever, hives, eczema
Yes No Glaucoma
Yes No Do you have any artificial joints, valves, metal pins
Yes No Disorders of the immune system (arthritis, joint pains)
Yes No Tattoos
Yes No Blood Transfusions
Yes No Venereal/ Sexually Transmitted Diseases (HIV)
Yes No Emotional Problems (depression, anxiety, panic disorder, etc.)
Yes No Rare disorders (hereditary angioedema, Malignant hyperthermia)
Yes No Do you require more anesthetic solutions than most people?


Please list history of any other medical illness not mentioned above and include the treatment

Please list history of previous hospital admissions

Please check the medication you are currently on:

Aspirin
Vitamin E
Coumadin
Clopidogrel
NSAIDS(ex.Mefenamic acid, Ibuprofen)
Ticlopidine
Warfarin
Heparin

List all prescription and non-prescription medications, vitamins and supplements that you are using which are not mentioned above

Do you have any allergy to medications and indicate name of drug?

Antibiotics
Anesthetics
Pain Relievers
Anti Inflammatory
Ointments or Creams
Others

Alcohol, Cigarette, and other drugs history:

Weekly Alcohol Intake
Weekly Cigarette Use
Weekly Other Drugs
Do you Smoke Now? YesNo How Many Packs Per Day
Have you tried to quit? YesNo
Can you go 8 hours without smoking? YesNo
If you have quit smoking, when did you quit?
How many packs did you smoke per day?

What did you use to quit?

Pertinent Family History:

Cancer
Heart disease
Epilepsy
Tuberculosis
Hypertension
HIV
Diabetes
Stroke
Hepatitis
Jakob Kurtzfeld

Please list down any other family diseases not mentioned above: