Adult Medical History (Single Form) Adult Medical History Form (Single) Step 1 of 5 20% Patient's Name First Middle Last Date of Birth Date Format: MM slash DD slash YYYY 1. Physician’s NamePhysician’s Address and Telephone #2. Are you under a physician’s care?YesNoSince when and Why?3. When was your last complete physical exam?4. Are you taking any medication or substances?YesNoMedications currently taking5. Do you routinely take health related substances? (Vitamins, herbal supplements, natural products)YesNo6. Are you allergic to any medications or substances?YesNoPlease list any allergies to medications or substances:7. Do you have any other allergies or hives? .YesNo8. Do you have any problems with penicillin, antibiotics, anesthetics or other medications?YesNo9. Are you sensitive to any metals or latex?YesNo 10. Are you pregnant or suspect you may be?YesNo11. Do you use any birth control medications?YesNo12. Have you ever been treated for or been told you might have heart disease?YesNo13. Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?YesNo14. Have you ever had rheumatic fever?YesNo15. Are you aware of any heart murmurs?YesNo16. Do you have high or low blood pressure? Yes No Please Explain:17. Have you ever had a serious illness or major surgery?YesNoDon't KnowIf so, explain18. Have you ever had radiation treatment, chemo treatment for tumor, growth or other condition?YesNo19. Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis?YesNo 20. Do you have inflammatory diseases, such as arthritis or rheumatism?YesNo21. Do you have any artificial joints/prosthesis?YesNoDon't Know22. Do you have any blood disorders, such as anemia, leukemia, etc?YesNo23. Have you ever bled excessively after being cut or injured?YesNo24. Do you have any stomach problems?YesNo25. Do you have any kidney problems?YesNo26. Do you have any liver problems?YesNo27. Are you diabetic?YesNo28. Do you have fainting or dizzy spells?YesNo29. Do you have asthma?YesNo30. Do you have epilepsy or seizure disorders?YesNo 31. Do you or have you had venereal or any sexually transmitted disease?YesNo32. Have you tested HIV positive?YesNo33. Do you have AIDS?YesNo34. Have you had or do you test positive for hepatitis?YesNo34. Have you had or do you test positive for hepatitis?YesNo35. Do you or have you had T.B.?YesNo36. Do you smoke, chew, use snuff or any other forms of tobacco?YesNo37. Do you regularly consume more than one or two alcoholic beverages a day?YesNo38. Do you habitually use controlled substances?YesNo39. Have you had psychiatric treatment?YesNo 40. Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?YesNo41. Do you have any disease condition, or problem not listed? If so, explain42. Is there anything else we should know about your health that we have not covered in this form?43. Would you like to speak to the Doctor privately about any problem?YesNo"I certify that the above information is complete and accurate"* First Last By typing your full name here, you are electronically signing this document.
