History Form
Please print and fill the following form and bring it to clinic.
Past Medical and Surgical History
Questionnaire
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