Patient Medical History

Patient Name:

Today's Date:

Date of Birth:

Allergies:

If you have no known allergies,please check the box.

No allergies to report

Medication:

Reaction:

And new medication and reaction

Major Illnesses:(please select all that apply)

Hypertension:

Current Past N/A

Notes:

Diabetes:

Current Past N/A

Notes:

Cancer:

Current Past N/A

Notes:

Other:

Current Past N/A

Notes:

Surgeries: ( please list all major surgeries with estimated dates)

If you have never had any major surgeries, please check the box.

No surgeries to report

Surgeries:

Add another surgery

Family History

Mother:

Hypertension

Diabetes

Cancer

N/A

Other (please specify):

Father:

Hypertension

Diabetes

Cancer

N/A

Other (please specify):

Brother:

Hypertension

Diabetes

Cancer

N/A

Other (please specify):

Sister:

Hypertension

Diabetes

Cancer

N/A

Other (please specify):

Grandmother (M):

Hypertension

Diabetes

Cancer

N/A

Other (please specify):

Grandmother (P):

Hypertension

Diabetes

Cancer

N/A

Other (please specify):

Grandfather (M):

Hypertension

Diabetes

Cancer

N/A

Other (please specify):

Grandfather (P):

Hypertension

Diabetes

Cancer

N/A

Other (please specify):

Social History:

Drink Alcohol:

Currently In the past Never

How much and how often?

Use tobacco products:

Currently In the past Never

How much?

Substance abuse:

Currently In the past Never

What substance?

Medication with dosage: (please use medication form)

If you are not currently taking any medications,please check the box.

No medications

Other Information:

Preferred Pharmacy Name:

Date of last Influenza shot:

Preferred Pharmacy address:

Menstrual Period:

Are you Pregnant

Are you Breastfeeding

Patient Acknowledgement:

To the best of my knowledge, the information provided above is accurate and complete.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

To the patient or Authorized Person's Signature:

Date:

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