Medical History Form

Patient Name
Gender
Family Status
SS#:
Birth Date
Home Phone/Work Phone
Mobile Phone / Pager
E-mail
Address
Primary
Secondary

HEALTH INFORMATION

  • Are you allergic to any of the following (please check all that apply) :
  • Have you ever had any of the following? Please answer Yes or No to each question by marking the boxes below.

  • Do you have any other health problems or conditions?
  • Are you taking any medications at this time?
  • Have you been admitted to a hospital or needed emergency care during the past year?
  • Are you now under the care of a physician?
  • Do you smoke?
  • Have you ever taken any diet drugs such as Phen-Phen, Redux, other?
  • Women: Are you pregnant now?
  • Do you take any birth control medication?
  • To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have anychange in my health, I will inform the doctors at the next appointment without fail.

    Signature of Patient