Template: Medical IntakeMedical History Form Form TemplateUse This Template Patient medical and health history form.This is a preview of the template. Click here to use it.Full Name *Date of Birth *Primary Care Physician Do you have any known allergies? *List of Current Medications *Do you have a history of the following conditions? *DiabetesHypertensionAsthmaHeart DiseaseCancerChronic PainArthritisHigh CholesterolOtherHave you had any surgeries? Are you currently under any medical treatment? Do you use any assistive devices (e.g., glasses, hearing aids)? GlassesContact LensesHearing AidsCane/WalkerWheelchairNoneDo you smoke? Do you consume alcohol? Family History of Medical Conditions Additional Information or Concerns Signature *Sign HereUse This Template