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Patient Medical History
Patient Medical History
davidlgreene1969
2017-08-31T13:00:48+00:00
Patient Medical History
Name
First
Last
Date of Birth
Is your reason for today's visit accident related?
Yes
No
Date of Injury
Please list the two main reasons only for today's appointment
Drug Allergies
Drug Allergies?
*
Yes
None
List medication and reaction experienced
Current Medications
Current Medication
Yes
None
List name of medication and dosage that you take on a regular basis.
Past Medical History
Past Medical History
Yes
None
Please circle if you have or have been treated for any of the following:
Anxiety
Asthma
Blood Clots
Lung Disease
Sleep Apnea
Allergies (seasonal)
Cancer
Colitis
CHF
Migraines
Stroke
COPD
Depression
Diabetes
Pneumonia
Thyroid
Insomnia
Drug Dependency
Hernia
Kidney Disease
Psychological
Ulcers/Gastritis
Dementia
High Cholesterol
Irritable Bowel
High Blood Pressure
Seizure Disorder
Pregnancy
Liver Issue
Surgical History
Surgical History
Yes
None
Check all that apply:
Appendix Removed
Gallbladder Removed
Fracture Repair
Pacemaker
Heart Bypass
Hysterectomy
Tubal ligation
Family Medical History
Family Medical History
Yes
None
Check all
Diabetes
High Blood Pressure
High Cholesterol
Cancer
Stroke
Thyroid Disease
Which Relative?
Mother
Father
Sibling
Tobacco/Alcohol/Drug Use
Current or Past Use of Tobacco/Alcohol/Drugs?
Tobacco
Alcohol
Drugs
None
Please Describe