Personal Medical History

Please complete this medical history as complete as you can so that we may provide the best care possible. Contact Information Date Your Name Date of Birth Describe any existing medical problems, if any.   Present Medications Prescription Medicine. How long. What is it for. How often.         Other Meds Yes No How Long. What For. How Often Aspirin, Tylenol or other pain medication Laxatives Other.               Past Medical History Check any of the following that you may have had and indicate approximate year Condition Yes No Year Condition Yes No Year Diabetes Epilepsy or Seizure Cancer Arthritis Heart Attack Glaucoma Heart Disease Blood Transfusion High Blood Pressure Recent Weight Change Stroke or Paralysis Other Ulcers ALLERGIES Gallstones Penicillin Kidney Stones Sulfa Thyroid Disease Other Medicines Blood Disease         Asthma         Lung Problems         Jaundice or other Liver Disease                         IMMUNIZATION Check the immunization shots you have had, and year you had them Condition Yes No Year Condition Yes No Year Diphtheria/Pertussis/Tetanus Measles/Mumps/Rubella Tetanus Pneumonia Polio Hepatitis