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Medical History Form
Patient Details
Name Surname
Date of Birth
Weight And Height
Address
Tel Home
Tel Work
Mobile
E - Mail
Next of Kin Details
Name Surname
Relationship
Address
Medical Information (Do you have or have you had)
AIDS or HIV+
No
Yes
Anemia
No
Yes
Arthritis
No
Yes
Asthma
No
Yes
Back Problems
No
Yes
Bladder Infection
No
Yes
Bleeding Tendency
No
Yes
Blood Clots
No
Yes
Bronchitis
No
Yes
Cancer
No
Yes
Colitis
No
Yes
Congenital Heart
No
Yes
Diabetes
No
Yes
Epilepsy
No
Yes
Fainting Spells
No
Yes
Goiter
No
Yes
Hay Fever
No
Yes
Hearth Attack
No
Yes
Hepatitis
No
Yes
High Blood Pressure
No
Yes
Kidney Disease
No
Yes
Leukemia
No
Yes
Liver Disease
No
Yes
Migraine
No
Yes
Nervous Breakdown
No
Yes
Pacemaker
No
Yes
Pain in the Chest
No
Yes
Palpitations
No
Yes
Pneumonia
No
Yes
Rheumatic Heart
No
Yes
Shortness of Breath
No
Yes
Stomach Ulcers
No
Yes
Stroke
No
Yes
Thyroid Disease
No
Yes
Tonsilitis
No
Yes
Tuberculosis
No
Yes
Other serious illness that you have had
Do you regularly smoke? (If yes, how much?)
No
Yes
Do you regulary drink 6 or more cups of coffee per day?
No
Yes
Do you regularly drink alcohol or beer? (If yes, how much?)
No
Yes
Have you recently had chest x-ray? (If yes, when?)
No
Yes
Any metal implants/devices (If yes, list?)
No
Yes
Do you wear spectacles?
No
Yes
Do you wear contact lenses?
No
Yes
Do you wear dentures?
No
Yes
Have you recently had a cold or flu? (If yes, when?)
No
Yes
Please list any medications (presription or over-the-counter) that you have taken within the last month
Are you presently taking any medications (If yes please list them)
Do you know of any blood relative who has or had any chronic or congenital disease (If yes please give all details)
Do you have any allergy? (If yes please give all details)
Past Surgeries
Date
Type
Hospital
Have you had complications or bad reactions to anesthesia ? (List)
No
Yes
Have you ever had a blood transfusion ? (If yes, when?)
No
Yes
Have you had a significant weight change in the last year ? (If yes, please give details)
No
Yes
Do you have frequently bleeding gums ?
No
Yes
Have you ever bled excessively from a tooth extraction ?
No
Yes
Do you bleed excessively from a laceration ?
No
Yes
Do you have nose bleeds (If yes, how often?)
No
Yes
Women Only
Is there any chance you may be pregnant ?
No
Yes
Number of Pregnancies
Number of Children
Are you still having regular menstrual periods ? (If yes, date of last menstrual period)
No
Yes
Date of last mammogram
Result
Do you have or have you had Sleep Apnea ? Please consider the following symptoms of sleep apnea
I am frequently tired upon waking and throughout the day
No
Yes
I have trouble staying asleep at night
No
Yes
I have been told that I snore or stop breathing during sleep
No
Yes
I wake up throughout the night or constantly turn from side to side
No
Yes
I have been told that my legs or arms jerk while I’m sleeping
No
Yes
I make abrupt snorting noises during sleep
No
Yes
I feel tired or fall asleep during the day
No
Yes
Do you have or have you had Deep Vein Thrombosis or Pulmonary Embolus ? any past or present history of any of the following
Past History of Blood Clots
No
Yes
Family History of Blood Clots
No
Yes
Birth Control Pills
No
Yes
Swollen Legs
No
Yes
History of Cancer
No
Yes
Large Dose Vitamins
No
Yes
Varicose Veins
No
Yes
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