Patient Medical History Form Step 1 of 3 33% Patient InformationToday's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Middle Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please tell us your areas of concern/what would you like to change?HeightWeightDo you smoke?Select OneYesNoHow many packs per day?How much alcohol do you drink?Select OneNoneOccasionalSocialDailyMore than 2 drinks a dayMore than 7 drinks a dayDo you have any allergies?Are you currently taking any vitamins, minerals or supplements?Select OneYesNoPlease list type and dosageAre you currently taking any medications?Includes CREAMS, PATCHES, INJECTIONS, and OTC MEDICATIONS.Select OneYesNoPlease list type, dosage and frequencyDo you have a history of any of the following bleeding problems?select all that apply Easy bleeding Von Willebrands Hemophilia Excessive clotting History of DVT History of PE Anemia Anticoagulation Other OtherDo you have problems with chronic dry eye which requires eye drops?Select OneYesNoHave you had Lasik surgery within the last six months?Select OneYesNoDo you wear contact lenses?Select OneYesNo Medical HistoryGeneral Historyselect all that apply Recent weight gain Recent weight loss Poor nutrition Chronic fatigue Other Other historyPsychiatric/ Neurologic Historyselect all that apply Seizures Depression Anxiety Fibromyalgia Other Other informationEar/Nose/Throat Historyselect all that apply Blepharospasm Hearing loss Wear glasses Vision loss Snoring/Apnea Other Other informationCardiac Historyselect all that apply HTN Hyper cholesterol CHF Myocardial infarction Arrhythmias Pacemaker Mitral Valve Prolapse Other Other informationPulmonary Historyselect all that apply Asthma PTX COPD Emphysem Other Other informationHepatic Historyselect all that apply Hepatitis A Hepatitis B Hepatitis C Cirrhosis Jaundice Gallstones Other Other informationRenal Historyselect all that apply Kidney stones Renal Insufficiency Renal failure Pyelonephritis Urinary tract infection Other Other informationGastrointestinal Historyselect all that apply Bleeding Ulcers Constipation Diverticulosis GERD Non-Bleeding Ulcers Hemorrhoids Irritable bowel Other Other informationPregnancy Historyselect all that apply Vaginal Delivery C-Section Delivery Recurrent UTI Incontinence Urethral Stricture Other How Many Vaginal Deliveries?How Many C-Section Deliveries?Other InformationExtremity Historyselect all that apply Varicose veins Chronic Edema Ulcers Difficulty Walking Other Other InformationBreast Historyselect all that apply Breast Mass, Left or Right Nipple Discharge, Left or Right History of Breast Feeding Intertriginous Rashe Other Other InformationEndocrine Historyselect all that apply Diabetes, diet controlled Diabetes, oral medication Diabetes, insulin dependent Hyperthyroid Other Other InformationInfectious Disease Historyselect all that apply HIV Oral Herpes Genital Herpes Genital Warts Other Other InformationAnesthesia Historyselect all that apply Difficult Intubation Difficult Extubation Post-Op Nausea/Vomiting Malignant Hypothermia Other Other InformationCancer Historyselect all that apply Skin Breast Lung Liver Colon Other Other InformationOther Health History Not Mentioned AboveDoes anyone in your family have a history of the following?select all that apply Abnormal bleeding Anesthesia Problems Autoimmune Disorders Cancer Diabetes Heart Disease Kidney Disease Liver Disease Lung Disease Endocrine Disease Other Other Information Past Surgical HistoryCosmetic surgery type and date:Other surgery type and date:Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
