Medical History Form
Your answers on this form will help us understand your medical concerns and conditions better. If you
are uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember
specific details.
Name_________________________________ Date of Birth____________ Today’s date__________
1. Personal Medical History
Please indicate if you have had any of the following problems currently or in the past.
Anemia
Yes
No
Kidney disease/stones
Yes
No
Arthritis
Yes
No
Liver disease/Hepatitis
Yes
No
Asthma/Emphysema Yes
No
Lung disease/pneumonia
Yes
No
Bladder infections
Yes
No
Pancreatitis
Yes
No
Chronic diarrhea
Yes
No
Rheumatic Fever
Yes
No
Diverticulosis
Yes
No
Skin disease
Yes
No
Diabetes
Yes
No
Sleep apnea
Yes
No
If yes, what age?_____
Stroke
Yes
No
Emotional problems Yes
No
Venereal disease/Syphilis
Yes
No
Epilepsy or Seizures Yes
No
Gonorrhea/Chlamydia
Yes
No
Gallstones
Yes
No
Thyroid disease/Goiter
Yes
No
Gout
Yes
No
Tuberculosis
Yes
No
Heart Disease
Yes
No
Tumors/Cancer
Yes
No
High Cholesterol
Yes
No
Ulcers (stomach or intestinal) Yes
No
High Blood Pressure Yes
No
Acid Reflux (Heartburn)
Yes
No
If yes to any of the above, please explain__________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
When was your last Tetanus shot given? _____________
2. Family History
Adopted, family history unknown.
Has anyone in your family (including grandparents, parents, brothers, sisters, or children) had any of
the following conditions?
Family Relationship:
Living/Deceased:
Alcoholism
Yes
No
__________________
________________
Anemia
Yes
No
__________________
________________
Arthritis
Yes
No
__________________
________________
Bowel/Colon Cancer
Yes
No
__________________
________________
Breast Cancer
Yes
No
__________________
________________
Depression
Yes
No
__________________
________________
Diabetes
Yes
No
__________________
________________
Heart Disease/Angina
Yes
No
__________________
________________
Hepatitis
Yes
No
__________________
________________
High Blood Pressure
Yes
No
__________________
________________
High Cholesterol
Yes
No
__________________
________________
Kidney Disease
Yes
No
__________________
________________
Strokes
Yes
No
__________________
________________
Thyroid Disorder
Yes
No
__________________
________________
Tuberculosis
Yes
No
__________________
________________
Other_________________
Yes
No
__________________
________________