Medical History Form
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Name Surname : [text-1]

Date of Birth : [text-2]

Weight : [text-3]

Height : [height]

Address : [text-4]

Phone Home : [tel-540]

Mobile : [tel-542]

E-Mail : [email-621]

MEDICAL INFORMATION (DO YOU HAVE OR HAVE YOU HAD)
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AIDS or HIV+ : [radio-1]

Anemia : [radio-2]

Arthritis : [radio-3]

Asthma : [radio-4]

Back Problems : [radio-5]

Bladder Infection : [radio-6]

Bleeding Tendency : [radio-7]

Blood Clots : [radio-8]

Bronchitis : [radio-9]

Cancer : [radio-10]

Colitis : [radio-11]

Congenital Heart : [radio-12]

Diabetes : [radio-13]

Epilepsy : [radio-14]

Fainting Spells : [radio-15]

Goiter : [radio-16]

Hay Fever : [radio-17]

Hearth Attack : [radio-18]

Hepatitis : [radio-19]

High Blood Pressure : [radio-20]

Kidney Disease : [radio-21]

Leukemia : [radio-22]

Liver Disease : [radio-23]

Migraine : [radio-24]

Nervous Breakdown : [radio-25]

Pain in the Chest : [radio-26]

Palpitations : [radio-27]

Pneumonia : [radio-28]

Rheumatic Heart : [radio-29]

Shortness of Breath : [radio-30]

Stomach Ulcers : [radio-31]

Stroke : [radio-32]

Thyroid Disease : [radio-33]

Tonsilitis: [radio-34]

Tuberculosis : [radio-35]

Other serious illness that you have had : [text-10] [radio-68]

Do you regularly smoke? (If yes, how much?) : [radio-69] [radio-36]

Do you regulary drink 6 or more cups of coffee per day? :[radio-70] [radio-37]

Do you regularly drink alcohol or beer? (If yes, how much?) : [radio-71] [radio-38]

Have you recently had chest x-ray? (If yes, when?) : [radio-72]

Any metal implants/devices (If yes, list?) : [radio-73]

Do you wear spectacles? : [radio-41]

Do you wear contact lenses? : [radio-42]

Do you wear dentures? : [radio-43]

Have you recently had a cold or flu? (If yes, when?) : [radio-74] [radio-44]

Please list any medications (presription or over-the-counter) that you have taken within the last month : [radio-75] [text-11]

Are you presently taking any medications (If yes please list them) : [text-12]

Do you know of any blood relative who has or had any chronic or congenital disease (If yes please give all details) : [radio-76] [text-13]

Do you have any allergy? (If yes please give all details) : [text-14]

PAST SURGERIES
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Date : [radio-83] [date-255]

Hospital :[radio-84] [text-16]

Have you had complications or bad reactions to anesthesia ? (List) : [radio-45]

Have you ever had a blood transfusion ? (If yes, when?) : [radio-46] = [text-17]

Have you had a significant weight change in the last year ? (If yes, please give details) : [radio-47]

Do you have frequently bleeding gums ? : [radio-48]

Have you ever bled excessively from a tooth extraction ? : [radio-49]

Do you bleed excessively from a laceration ? : [radio-50]

Have you ever had a blood transfusion ? (If yes, when?) : [radio-51] = [text-18]

WOMEN ONLY
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Is there any chance you may be pregnant ? : [radio-78] [radio-52]

Number of Pregnancies : [radio-79] [text-19]

Number of Children :[radio-80] [text-20]

Are you still having regular menstrual periods ? (If yes, date of last menstrual period) : [radio-53] = [text-21]

Date of last mammogram :[radio-81] [text-22]

Result :[radio-82] [text-23]

DO YOU HAVE OR HAVE YOU HAD SLEEP APNEA ? PLEASE CONSIDER THE FOLLOWING SYMPTOMS OF SLEEP APNEA
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I am frequently tired upon waking and throughout the day : [radio-54]

I have trouble staying asleep at night : [radio-55]

I have been told that I snore or stop breathing during sleep : [radio-56]

I wake up throughout the night or constantly turn from side to side : [radio-57]

I have been told that my legs or arms jerk while I’m sleeping : [radio-58]

I make abrupt snorting noises during sleep : [radio-59]

I feel tired or fall asleep during the day : [radio-60]

DO YOU HAVE OR HAVE YOU HAD DEEP VEIN THROMBOSIS OR PULMONARY EMBOLUS ? ANY PAST OR PRESENT HISTORY OF ANY OF THE FOLLOWING
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Past History of Blood Clots : [radio-61]

Family History of Blood Clots : [radio-62]

Birth Control Pills : [radio-63]

Swollen Legs : [radio-64]

History of Cancer : [radio-65]

Large Dose Vitamins : [radio-66]

Varicose Veins : [radio-67]

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