Health History Form	Date Information Verified/By:
PATIENT NAME

HEALTH HISTORY	YES	NO	MEDICATIONS List medications, including aspirin, laxatives, birth control pills, all prescriptions, cough medicines, supplements (vitamins and herbal). You may bring your own medication list.
1. Cancer
2. Diabetes			Name Dose Frequency Last Dose FAMILY HISTORY SEX AGE ILLNESS OR CAUSE OF DEATH FATHER MOTHER Brothers/Sisters (use pulldown to select sex)   F M   F M Husband/Wife Sons/Daughters (use pulldown to select sex)   F M   F M HEALTH HISTORY YES NO   Previous Hospitalization Previous Surgery(ies) Serious Illness Serious Injury(ies) History of Problems with Anesthesia:   Self Family Steroids Transfusion Reaction Pregnant
3. Heart Disease
4. Heart Attack
5. Rheumatic Fever
6. Congenital
7. High Blood Pressure
8. Palpitations / Flutter
9. Pacemaker
10. Respiratory Disease
11. Chronic Cough
12. Hay Fever
13. Shortness of Breath
14. Asthma
15. Positive TB Test
16. Seizures / Strokes
17. Loss of Consciousness
18. Bleeding Tendency
19. Digestive Disease
20. Colitis
21. Stomach Ulcers
22. Hiatal Hernia / Reflux
23. Liver Disease
24. Genital / Urinary
25. Kidney Disease
26. Difficulty Voiding
27. Menstrual Difficulties
28. Sexual Dysfunction
29. Arthritis
30. Goiter / Thyroid Disease
31. Migraine Headache
32. Mental Illness
33. Depression
34. Nervous Breakdown
ALLERGIES
(Drug or other) Latex Rubber:   Yes No Unknown Shellfish:   Yes No Unknown X-ray dye:   Yes No Unknown
COMMENTS
PERSONAL HABITS (Check appropriate box) Yes No Do you regulary smoke? Cigarettes Pipe Cigars   For how many years? How many? Quit   Yes No Do you usually drink over 6 cups of coffee per day? Yes No Do you drink alcohol?      1 oz. per day    2 oz. per day    4 oz. per day    over 6 oz. per day    Occasional/Social BEER   1 bottle per day   2 bottles per day  over 4 bottles per day Yes No Do you use recreational drugs or have a history of drug abuse? Yes No Do you have difficulty in falling asleep? If yes, how often? Yes No Do you exercise regularly? Yes No Are you currently experiencing any pain or discomfort? If yes, please indicate the level of pain on this scale with (0) zero being no pain. 0 1 2 3 4 5 6 7 8 9 10