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MEDICAL HISTORY
Condition
Seasonal Allergies
Drug Allergies (Please
List)
Other allergies?
HEENT Disorders
History of HA’s
Other
Cardiovascular
HTN
CAD
Stroke
Other
Respiratory
Asthma
TB
Pneumonia
Chronic Pulmonary
Disease
Other
Endocrine & Metabolic
Diabetes Mellitus
Thyroid Disorder
Pancreatic disorder
Other
Immune System
AIDS
Collagen Vascular
Disease
Other
Hematology & Lymphatic
Thrombocytopenia
Anemia
Cancer
Lymphoma
Other
Dermatological
Rashes
Lesions
Musculoskeletal
Pain
Arthritis
Weakness
Other
Gastrointestinal/Digestive
GERD
Hepatitis A, B or C
Peptic Ulcer Disease
Other
Genitourinary
Kidney stones
Renal Insuffiency
YES
NO
Description (if
needed)
Start Year of
Diagnosis or
Condition
Still Present?
(circle one)
Yes or No
Yes or No
If still present,
is medication
required?
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Condition
Prostate disorder
Other
Neurologic/ Psychiatric
Depression
Anxiety
Seizures
Other neurologic
Procedures/surgical
history
YES
NO
Description
Start Year of
Diagnosis or
Condition
Still Present?
(circle one)
Yes or No
Yes or No
If still present,
is medication
required?
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Other Medical History
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