Medical History Form

708.771.0330

333 Circle Avenue, Forest Park, IL 60130

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Patient

Physician

Please list all medications you are currently taking with dosage:

List all allergies:

Are you pregnant

Yes

No

Nursing?

Yes

No

Taking birth control pills?

Yes

No

Indicate which of the following you have had, or have at present? (Check all that apply).

AIDS

Allergies or Hives

Anemia

Anxiety Problems

Arthritis, Rheumatism

Artificial Heart Valves

Artificial Joints

Asthma

Back Problems

Blood Disease

Cancer

Chemical Dependency

Chemotherapy

Circulatory Problems

Cold Sores

Cortisone Treatmen

Cough, Persistent

Cough up blood

Diabetes

Epilepsy

Fainting

Glaucoma

Headaches

Heart Murmur

Heart problems

Hemophilia

Hepatitis

High Blood Pressure

HIV Positive

Jaw Pain

Kidney Trouble

Latex Sensitivity

Liver Disease

Mitral Valve Prolapse

Neurological Problems

Pacemaker

Psychiatric Care

Radiation Treatment

Rheumatic Fever

Scarlet Fever

Shortness of Breath

Sinus Problems

Skin Rash

Stroke

Swelling of Feet/Ankles

Thyroid Problems

Tobacco Habit

Tonsillitis

Tuberculosis

Ulcers

Veneral Disease

Other:

Please describe any positive responses from the list above:

Do you smoke?

Yes

No

Describe

Do you use alcohol?

Yes

No

Describe

Do you use recreational drugs?

Yes

No

Describe

Have you had surgery or been hospitalized in the last 5 years?

Yes

No

Describe

Your Signature

Date

Thanks for submitting!

708.771.0330

333 Circle Avenue, Forest Park, IL 60130