Medical History Form

Patient medical and health history form.

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 CholesterolOther

Have 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/WalkerWheelchairNone

Do you smoke?

Do you consume alcohol?

Family History of Medical Conditions

Additional Information or Concerns

Signature *

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