Online Medical History Form


Please correct the errors described below.

1. General information:

2. Please list any allergies to food, drugs or latex

Add another allergy

3. Please list all medications you are currently taking, or have recently taken. Include the dose and frequency (once a day, etc.). Be sure to include aspirin, blood thinners, cortisone, and over-the counter drugs.

Add another medication

4. Please list any previous surgeries, including year, type of anesthesia and if any reactions occurred. Please include any childbirth.

Add another surgery

5. Do you have a history of any of the following: If "Yes", please comment

Patients over the age of 65:

The above is correct to the best of my knowledge.

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