Medical History
Information about the medical history of you and / or your relatives.

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Patient Information
Name
SSN
Marital Status
Sex
Ethnic Origin
Birth Date
Age
Occupation / Student
Person to Notify in Emergency
Name
Phone
Relationship
Last Physical Examination
Date
By Doctor
Doctor's Phone
Family or Referring Doctor
Name
Doctor's Phone
Present Medical Symptoms
Describe briefly your present medical symptoms and anything else that we should know
Recent Operations
OperationYear
Family History
Condition Relationship
Asthma
Arthritis
Allergies
Anemia
Alcoholism
Bleeding Tend.
Cancer
Colitis
Congenital Heart
Diabetes
Epilepsy
Goiter
High Bld. Pressure
Heart Disease
Hay Fever
Insanity
Kidney Disease
Leukemia
Migraine
Nervous Breakdown
Obesity
Rheumatism
Rheumatic Fever
Stroke
Suicide
Stomach Ulcers
Tuberculosis
Test and Immunizations Year Done
Tetanus
Diptheria
Measles
Mumps
Rubella
Polio
Flu Shot
Pneumonia Vaccine
TB Skin Test (P.P.D.)
Have You Ever Had? Year
Viral Hepatitis
Gonorrhea
Syphilis
Tuberculosis
Other
Current Medications
Drug Allergies
Habits
Do You: Amounts
Smoke
Drink Coffee
Drink Alcohol
Drink Beer
Travel
Traveled To: Year
Africa
Asia
Central America
Pets
Do you have any pets?