MEDICAL HISTORY QUESTIONNAIRE
Name: ______________________________________________________ Age: ______________________
Chief Complaint: ___________________________________________________________________________________ FAMILY HISTORY: Give age if living or age and cause of death.
Father _____________________________________ Mother _________________________________ Siblings ____________________________________ Children ________________________________
Is there an immediate family history (someone related by blood) of any of the fol owing:
ALLERGIES AND SENSITIVITIES: Indicate which, if any are present: MEDICATIONS: List al medications you currently take:
Sedatives, Sleeping Pil s, Tranquilizers
Digitalis, Nitroglycerine, Cardiac Drugs
Appetite Suppressants- including Phen-Fen
SOCIAL HISTORY (circle one) Tobacco: SURGICAL HISTORY: List al prior surgeries, as wel as cosmetic (including chemical peels). Type: ________________________
Date: _________________________ Surgeon: ________________________
Date: _________________________ Surgeon: ________________________
Date: _________________________ Surgeon: ________________________
Did you experience any problems or complications during or fol owing above procedures? No________
Please explain_____________________________________________________
_________________________________________________________________________________________________ PAST MEDICAL HISTORY: List any prior hospitalizations below (e.g. accidents, surgeries, etc.). Purpose: ______________________ Date: _________________________ Physician: _______________________
Purpose: ______________________ Date: _________________________ Physician: _______________________
Purpose: ______________________ Date: _________________________ Physician: _______________________
Have you recently been under the care of a physician for any reason?
If yes, please explain: ______________________________________________________________________________ _________________________________________________________________________________________________ Name, Address & Telephone Number of Physician: _______________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ REVIEW OF SYSTEMS: Check if any apply:
Is there any history not noted above of which the doctor should be aware?
If yes, please explain: ______________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ This information is correct and true to the best of my knowledge. Patient Signature: ______________________________________________
Parent/Guardian Signature: _______________________________________
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