Medical History Form |

Patient's Name

Age

Height

Weight

BMI

Gender

Physician's Name

Dentist's Name

Preferred Pharmacy for Rx:

Location:

Have you been a patient in the hospital during the past year?
Yes No

In the past two (2) years, have you had a serious illness requiring a physician’s care?
Yes No

List medications/drugs you are taking

List prior operations/hospitalizations

Misc/Other Questions

None of the Below

Do you smoke?
Yes No

If yes, how much per day?

Do you drink alcohol?
Yes No

If yes, how much per day?

Do you take recreational drugs?
Yes No

If yes, how much per day?

Do you have or have you had any disease, condition or problem not listed?
Yes No

If yes, please list

For Women Only

None of the Below

Are you taking birth control pills?
Yes No

Are you nursing?
Yes No

Are you pregnant?
Yes No

If yes, what month?

I understand the above information is necessary to provide safe surgical treatment. I have answered all questions truthfully and to the best of my knowledge.

Medical History Form

Form 2 of 4

Indicate which of the following you have had or have at present. Circle ”yes” or ”no” to each item

Are you sensitive or allergic to any of the following medications?

Misc/Other Questions

For Women Only

-Karen H.

-Colt N.

-Kimberly P.