MEDICAL HISTORY FORM

Today's Date:

Patient Name:

Date of Birth:

Chart Number:

Local Pharmacy Name & Phone #:

Mail Order Pharmacy Name & Phone #:

REASON FOR TODAY’S VISIT:

Includes medications, anesthetics, latex, foods, etc. Please list name and reaction

Please list prescription medications, over-the-counter, etc.

OTHER:

Please list type and approximate date(s)

If you checked Smoke, please specify how much:

If you checked Drink, please specify how much:

If you checked Drugs, please specify: