Medical History Form

Patient Name   

Date of Visit   

Date of Birth   

Age   

Physician Information: Please provide the names and contact information for all the doctors involved in your care.

Physician Name   

Office Address   

Specialty   

Hospital Affiliation   

Phone   

Fax   

Add another?     

Name   

Dosage   

Frequency   

Add another?     

No Prior Surgeries or Procedures

Type of Surgery/Procedure   

Date   

Hospital/Clinic
where Performed   

Add another?

Do you have an Internal Electronic Device (i.e. defibrillator/pacemaker)?   
Yes    No   

Type   

Date   

Add another?

No known allergies     

Allergy   

Reaction   

Add another?

Whom do you live with?   

Do you have children?   
Yes    No   

Do you drink alcohol?   
Yes    No   

If you used to drink, when did you stop?   

Do you/did you use tobacco products (cigars/cigarettes/tobacco)?   
Yes    No   

Do you/did you use E-cigarettes?   
Yes    No   

Do you use recreational drugs?   
Yes    No   

Do you have special religious, spiritual, or cultural needs that we should be aware of?   
Yes    No   

Do you have Advanced Directives (living will, power of attorney for health care)?   
Yes    No   

Mother     

Father     

Sibling     

Other     

Adopted     

No significant family