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Medical History
Patient Name
First
Last
Medication Allergies
Yes / No (list)
Current Medications
Include over-the-counter medications
Symptoms
Please check any of the following symptoms that you currently have to any significant degree or may have had in the past.
Alcoholism
Anemia
Asthma
Anorexia
Arthritis
Appendicitis
Bleeding disorder
Blood clots
Back pain (severe)
Breast lump
Bulimia
Blurred vision
Bloating / Gas
Bowel disease
Balance problems
Cancer
Cataracts
Chemical dependency
Constipation (chronic)
Chest pain
Change in vision
Circulation problems
Cholesterol problem
Cough (persistant)
Depression
Diarrhea
Diabetes
Dizziness / Fainting spells
Drug Abuse
Eczema
Emphysema
Epilepsy (seizure)
Erection difficulties
Fatigue (chronic)
Fibromyalgia
Glaucoma
Goiter
Gallstones
Gout
Hives / Rashes
Hay fever
HIV positive
Herpes
Hepatitis
Headaches (frequent)
Hearing loss
Heart Murmur
Heartburn / Indigestion
High Blood Pressure
Heart Disease
Hemorrhoids
Hot flashes
Irritible Bowel
Heartbeat - rapid/irregular
Kidney stones
Lupus
Leg / Ankle swelling
Liver Disease
Memory Problems
Multiple sclerosis
Migraines
Menstrual irregularities
Nausea (chronic)
Nervousness
Numbness / Tingling
Nervous Breakdown
Osteoporosis
Pap smear abnormal
Pacemaker
Polio
Prostate problems
Psychiatric illness
Pulmonary embolism
Psoriasis
Rheumatic fever
Rectal bleeding
Seizures
Steroid use
Skin lesion changes
Sickle Cell
Sinuses (chronic)
Swallowing Problem
Sweating - abnormal
Sleep disturbance
Suicide attempt
Stroke / TIA
Shortness of breath
Sexually transmitted disease
Tremor (shaking)
Tuberculosis
Thyroid (underactive)
Thyroid (overactive)
Thirst excess
Tinnitus (ear ringing)
Ulcers
Urine - blood
Urination excess
Urine incontinence
Vision changes
Varicose veins
Please print and bring with you on your visit.
