Medical History Update FormPlease enable JavaScript in your browser to complete this form.General InformationName *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeHealthcare Provider InformationName of Your Medical DoctorMedical Doctor Phone NumberDate of Last VisitMedical Health HistoryHeart problems:YesNoChest painYesNoShortness of breathYesNoBlood pressure problemYesNoHeart murmurYesNoHeart valve problemYesNoTaking heart medicationYesNoRheumatic feverYesNoPacemakerYesNoArtificial heart valveYesNoBlood problems:YesNoEasy bruisingYesNoFrequent nosebleedsYesNoAbnormal bleedingYesNoBlood disease (anemia)YesNoEver require a blood transfusion?YesNoAllergy Problems:YesNoHay feverYesNoSinus problemsYesNoSkin rashesYesNoTaking allergy medicationYesNoAsthmaYesNoIntestinal Problems:YesNoUlcersYesNoWeight gain or lossYesNoSpecial dietYesNoConstipation/DiarrheaYesNoKidney or bladder problemsYesNoBone or Joint Problems:YesNoArthritisYesNoBack or neck painYesNoJoint replacement (e.g. total hip, pins, or implants)YesNoAre you taking or have you taken Bisphosphonate (e.g., Fosamax, Boniva, Actonel, Atelvia, Reclast, etc.)YesNoFainting Spells, Seizures or EpilepsyYesNoStroke(s)YesNoFrequent or severe headachesYesNoThyroid problemsYesNoPersistent cough or swollen glandsYesNoPremedications required by physicianYesNoCancer/tumorYesNoDiabetesYesNoUrinate more than 6 times a dayYesNoThirsty or mouth is dry much of the timeYesNoFamily history of diabetesYesNoTuberculosis or other respiratory diseaseYesNoDo you drink alcohol?YesNoIf so, how much?Do you smoke?YesNoIf so, please describeHepatitis, jaundice, or liver troubleYesNoHerpes or other STDYesNoHIV-positive / AIDSYesNoGlaucomaYesNoDo you wear contact lenses?YesNoHistory of head injury?YesNoEpilepsy or other neurological disease?YesNoHistory of alcohol or drug abuse?YesNoDo you have any disease, condition, or problem not listed previously that you feel we should now about?YesNoIf so, please describePlease list any recent surgeries and dates:Are you allergic, or have you reacted adversely to any of the following?AspirinYesNoCodeineYesNoDental AnestheticsYesNoErythromycinYesNoJewelryYesNoLatexYesNoMetalsYesNoPenicillinYesNoTetracyclineYesNoSulfaYesNoOtherYesNoPlease list any medications you are currently taking:For Women:Are you taking birth control pills or other hormones?YesNoAre you pregnant?YesNoIf yes, number of weeks:Are you nursing?YesNoHave you reached menopause?YesNoIf so, do you have any symptoms?NameSubmit