History Form

Please print and fill the following form and bring it to clinic.


Past Medical and Surgical History
Please mark all that may apply to you. Please add detailed information on back. 
o       Allergies____________________________
o       Medication Allergies___________________
o       Smoker Current    Yes___ No___ How many years Smoked
o       Smoker Former     How many years Smoked___ Quit when? __________ 
o       Life Style     Stressful __ Active __ Sedentary__
o       Occupation __________________________
o       Post Menopausal   ___Natural    ___Surgically
      Have you been treated for the following conditions?
Please mark below:
o        Heart Attack                                                                                                                      
o        Angina                                                                                              
o        A- Fibrillation                                                                         
o        Palpitations / Irregular heart beat                                             
o        High Blood Pressure                                                              
o        Heart Disease / Heart Failure                                                                                              
o        Thyroid Disease                                                                                                                  
o        Anemia                                                                                                                             
o        Diabetes   Diet Controlled / Medicine                                       
o        Gout                                                                                     
o        Kidney disease                                                                      
o        Blood clot                                                                              
o        Depression                                                                            
o        Pneumonia                                                                            
o        Rheumatic Fever                                                                    
o        Hepatitis / Liver disease                                                          
o        Cancer           What Kind_________ What kind of treatment?_________________
o        Osteoporosis                                                                         
o        High Cholesterol                                                                    
o        Asthma                                                                                                                            
o        Migraine Headaches                                                               
o        Gall Bladder Disease                                                                                                           
o        Peptic / Bleeding Ulcer                                                                                                        
o        Seizures                                                                               
o        Strokes                                                                                 
o        Mini strokes                                                                          
o        Emphysema                                                                          
o        Anxiety                                                                                 
o        Pacemaker / Defibrillator                                                         
o        Arthritis / Back Pain / Neck Pain                                             
o        Trouble Sleeping / Day time Tiredness