Medical History Form

Patient Name:

Date:

Reason for today’s visit:

Do you have now, or have you ever had diseases or conditions of: (If YES, Please check box)

Lungs:

Bronchitis

Emphysema

Asthma

Chronic Cough

Morning Cough

Vascular:

High Blood Pressure

Chest Pain

Heart Attack

Heart Murmur

Irregular Heartbeat

Mitral Valve Prolapse

Pacemaker

Blood Clots/Phlebitis

Other Systemic:

Diabetes

Thyroid

Kidney

Bladder

Joint/Muscle/Arthritis

Bowel

Cancer

Stomach

Hepatitis A/B/C

Current Medication:

Do you have allergies to food or medicine?

Yes No

If Yes, Please List:

Do you currently use any prophylactic antibiotics?

Yes No

If Yes, Please List:

Do you drink alcohol?

Yes No

If Yes, Please List:

Amt per day:

Do you currently use IV Drugs?

Yes No

If Yes, Please List:

Amt per day:

Do you currently take any medications?

Yes No

If Yes, Please List:

Have you ever been exposed to HIV/AIDS?

Yes No

Have you ever had dental anesthesia (Novacaine)?

Yes No

Ever had a blood transfusion?

Yes No

Are you Latex Intolerant?

Yes No

Any adverse Reaction?

Yes No

Skin

Have you ever had Skin Cancer?

Yes No

If yes, location(s):

Family History of Skin Cancer?

Yes No

Relationship:

Do you currently use skin care products?

Yes No

If yes, what brand?

When exposed to the sun, do you:

Tan Tan & Burn Burn

List any other disease or condition we should be aware of:

List surgical procedures performed within the last 6 months:

Please answer the following questions:

Do you smoke?

Yes No

Do you bleed easily?

Yes No

Are you pregnant?

Yes No

If no, date of last menstrual period:

Do you have artificial joints, pins or screws?

Yes No

Do you currently use skin care products?

Yes No

Do you require antibiotics prior to surgery?

Yes No

What is your occupation?

Completed by:

Patient: (Initial)

Date:

Nurse: (Initial)

M.A. (Initial)

Signed by:

Physician:

Date:

Reviewed by:

Date:

Pharmacy Location:

Preferred Pharmacy:

Pharmacy Telephone Number:

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