Patient Medical History

Date

Patient Name

Gender

M F U

DOB

Height

Weight

Past Medical History (Please answer all questions to the best of your ability):

Do you now or have you had:

Tuberculosis (TB)

Yes No

Thyroid Disease

Yes No

Cancer

Yes No

Stomach Disease (ulcers, reflux)

Yes No

High blood pressure

Yes No

Intestinal Disease

Yes No

Diabetes (sugar high/low)

Yes No

Liver Disease

Yes No

Heart attack

Yes No

Seizures

Yes No

Kidney Disease

Yes No

Urinary issues

Yes No

Lung Disease

Yes No

Other

Yes No

Cancer: Specify Type

Diabetes: Specify if Sugar High or Low

If other, please specify.

Please explain all of the “YES” answers

Habits: Do you now or have ever used:

1) Tobacco (cigarettes, chew, pipes, vape, etc)

Yes No

If yes, how long?

Quit?

Yes No

2) Alcohol (beer, liquor, wine, etc)

Yes No

If yes, how long?

3) Caffeine (soda, coffee, tea, energy drinks, etc.)

Yes No

How many per day?

4) Illicit drugs (injected, inhaled, etc)

Yes No

Routinely (w/ doses)

If yes, quit?

Yes No

Total years

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Patient Medical History

Medication Allergies/Intolerance (Reaction)

Food and Environmental Allergies (Reaction)

Prior Surgeries

Medications Taken