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Blog
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Intake Form
Home
About Us
Services
FAQ
Blog
Contact Us
Home
About Us
Services
FAQ
Blog
Contact Us
Intake Form
PATIENT MEDICAL HISTORY FORM
General Patient Information
Patient Gender :
Patient Name :
Patient Height (ft/in) :
Patient Weight (lbs) :
Date of Birth :
Age :
Address :
City :
State :
Zip Code:
Patient E-Mail :
Reason for visit / consultation :
Patient Medical History :
Please list any drug allergies :
Do you take any diabetes medication?
Yes
No
Have you ever had (Please check all that apply)
Anemia
Asthma
Arthritis
Cancer
Gout
Emotional Disorder
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
Other illnesses :
Please list any Operations and Dates of Each:
Please list your Current Medications :
Are you pregnant?
Yes
No
Healthy & Unhealthy Habits :
Exercise :
Never
1-2 days
3-4 days
5+ days
Alcohol Consumption :
I don’t drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Caffeine Consumption :
I don’t use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Eating following a diet :
I have a loose diet
I have a strict diet
I don’t have a diet plan
Include other comments regarding your Medical History :
Have you or any member in your family with history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2)?
Yes
No
If yes, who?
Send
