MEDICAL HISTORY

Patient's Last Name:

Patient's First Name:

Middle Initial

Other

Surgeries you have had

Hospitalization other than for the surgeries listed

Family Physician

Last visit date

Are you now, or have you been, under any other doctor's care for any reason over the past two years?

Yes No

If yes, please explain

MEDICATIONS

Include prescriptions, over-the-counter medications and vitamins

Pharmacy Name(s)

Pharmacy Phone(s)

Do you take oral contraceptives?

Yes No

If other, specify:

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Signature of Patient, Parent, Guardian or Personal Representative

Date

Please print name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

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