Health History

Name*
Email Address*
DATE OF BIRTH*
Month
Day
Year
AGE
TODAY’S DATE
Month
Day
Year
REFERRED BY
PRIMARY DOCTOR
REASON FOR TODAY’S VISIT
Medication
(PRESCRIPTION AND OVER-THE-COUNTER)
(PRESCRIPTION AND OVER-THE-COUNTER)
Medication Dosage Frequency
NON-STEROIDAL DRUG USE?
(Ex: Aleve, Ibuprofen, Motrin, etc.)
- Yes
- No
DO YOU TAKE ASPIRIN?
- Yes
- No
DO YOU USE HERBAL PRODUCTS?
- Yes
- No
DO YOU TAKE MULTIVITAMINS?
- Yes
- No
DO YOU TAKE BLOOD THINNERS?
- Yes
- No
Allergies
ALLERGIES
(CHECK ALL THAT APPLY)
- NONE
- DEMEROL
- LATEX
- VERSED
- PENICILLIN
- CODEINE
- SULFA
- IVP DYE
- ENVIRONMENTAL (e.g., dust, mold, pollen)
- Other
Other Allergies
Have you ever had an unusual reaction to general or local anesthetic?
- Yes
- No
Explain
Have you ever received a blood or a blood-product transfusion?
- Yes
- No
Year
PAST MEDICAL HISTORY
PAST MEDICAL HISTORY
(CHECK ALL THAT APPLY)
- HEART DISEASE
- ASTHMA
- ARTHRITIS
- LUNG DISEASE/COPD
- COLON POLYPS
- HIGH BLOOD PRESSURE
- COLON CANCER
- KIDNEY DISEASE
- SEIZURES/EPILEPSY
- CELIAC DISEASE
- GLAUCOMA
- COLITIS/CROHN’S DISEASE
- CONGESTIVE HEART FAILURE
- STROKE
- THYROID DISEASE
- HEPATITIS/LIVER DISEASE
DIABETES:
CANCER – TYPE:
OTHER:
FEMALES – IS THERE ANY CHANCE THAT YOU ARE PREGNANT?
- Yes
- No
PREVIOUS SURGERIES/PROCEDURES
PREVIOUS SURGERIES/PROCEDURES
(CHECK ALL THAT APPLY)
- HERNIA
- BACK
- APPENDIX
- TONSILS
- GALLBLADDER
- BREAST
- HYSTERECTOMY
- PACEMAKER IMPLANT
- TUBAL LIGATION
- DEFIBRILLATOR IMPLANT
- HIP REPLACEMENT
- KNEE REPLACEMENT
- HEART BYPASS SURGERY
- HEART VALVE REPLACEMENT
EGD – DATE:
COLONOSCOPY – DATE:
COLON, INTESTINAL, STOMACH SURGERY — DATE:
OTHER:

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Medication

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PAST MEDICAL HISTORY

PREVIOUS SURGERIES/PROCEDURES

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SOCIAL HISTORY

REVIEW OF SYMPTOMS

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Medication	Dosage	Frequency