Medical History Form

Patient name       _______________________________________

Date of birth        _______/_______/______

Medical history - please tell us if you have ever been treated or taken medication for (circle disease or disorder):

High blood pressure     Coronary Artery Disease (clogged heart arteries)     Heart attack (myocardial infarction)     Irregular heartbeat     Atrial fibrillation

Stroke     COPD     Emphysema/bronchitis     Asthma     Other lung disorder (what type?___________________________)       Sleep apnea         Need for CPAP/BPAP

Bleeding or blood clotting disorders   (Von Willebrand's     Hemophilia     Sickle cell disease or trait     Thalassemia     Leukemia     Lymphoma 

           Leiden deficiency     personal history of blood clots

Chronic kidney disease     Kidney failure     Prostrate cancer     Enlarged Prostrate (BPH)    Peripheral vascular disease (clotted arteries in legs or arms)

Diabetes     Gout     Osteoporosis/osteopenia    GERD/gastroesophageal reflux/heartburn

 Cancer (what type please and what treatment?    ______________________________________________________________________________________

Reaction to anesthesia     Depression     Anxiety disorder      Mental illness     Claustrophobia     Drug or Alcohol Addiction

Migraine headaches     Neuropathy     Seizures     HIV/AIDS    MRSA infection     Liver disease or cirrhosis

Other disease or disorder?  _____________________________________________________________________________________________________________

Have you ever smoked?     NO          YES, but I quit in ____________    YES, I smoke  ________ packs per day

Do you take oral tobacco or snuff?     NO      YES

Do you drink alcohol?   YES       NO

Are you allergic to any medications?     NO     YES

If yes, please list__________________________________________________________________________________________________________________________

Please list surgeries that you had with approximate dates

____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________

Please list your Medications (or bring in a prepared list)

Name                   Dose (mg, drops, etc.)           Frequency  (how often) 

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________