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Medical History
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Depression
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Stroke
|
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Migraines
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Head Injury
|
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Seizures
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Anemia
|
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Bleeding Disorder
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Blood Clots/DVT
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Asthma
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Pulmonary Embolism
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Tuberculosis
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Emphysema
|
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Heart Disease
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High Blood Pressure
|
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Skin Disorder
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Autoimmune
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Lupus/Scleroderma
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Pigmentation
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Nasal Airway Obstruction
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Diabetes
|
|
Hepatitis
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Cancer
|
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Other Medical Condition
|
Medical History Comments
|
|
Family History
|
|
|
Depression
|
Stroke
|
|
Migraines
|
Head Injury
|
|
Seizures
|
Anemia
|
|
Bleeding Disorder
|
Blood Clot/DVT
|
|
Asthma
|
Pulmonary Embolism
|
|
Tuberculosis
|
Emphysema
|
|
Heart Disease
|
High Blood Pressure
|
|
Skin Disorder
|
Autoimmune
|
|
Lupus/Scleroderma
|
Pigmentation
|
|
Nasal Airway Obstruction
|
Diabetes
|
|
Hepatitis
|
Cancer
|
|
Other Medical Condition
|
Medical History Comments
|
|
Surgeries
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Have you ever had surgery?
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Type of Surgery
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Date of Surgery
|
|
Type of Surgery
|
Date of Surgery
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Type of Surgery
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Date of Surgery
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|
Any anesthesia problems?
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Describe Anesthesia Problems
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Hospitalization
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Ever Hospitalized?
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Reason for Hospitalization
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Date of Hospitalization
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Reason for Hospitalization
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Date of Hospitalization
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Social History
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Height
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Weight
|
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Do you smoke?
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If yes, how much?
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Do you drink?
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If yes, how much?
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Do you use illegal drugs?
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If yes, how much? List drug(s)?
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Female Only Questions
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Get Regular Periods?
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Going through menopause?
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Pregnant or Lactating?
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