Existing Patient Health History Form

Name*

Email *

Phone *

PERSONAL MEDICAL HISTORY (Existing Patient) Review of Systems:

Please check if any of the following applies to you, past or present:

If Other, Please state

If Cancer, list Type

If Other, Please state

Hematological

None Anemia Leukemia Other

If Other, Please state

Gastrointestinal

None Crohn’s Disease Colitis Other

If Other, Please state

Ear/Nose/Throat

None Hearing Loss Upper Respiratory Infection Other

If Other, Please state

Allergies (please list)

None Drug/Medication Environmental Other

If Drug/Medication, please list

If Environmental, please list

If Other, Please state

Please list any physical reaction to any medication allergies:

Alcohol Use?

Yes No

Amount

Tobacco Use?

Current Past Never

Type

Amount

# of Years

Have you ever been treated with oral prednisone?

Yes No

Please list any medication that you are taking OR ASK OUR STAFF TO MAKE A COPY OF YOUR MEDICATION LIST

Has anyone in your immediate family (Maternal/Paternal grandparents, parents, brothers, sisters, children -- living or deceased) been diagnosed with: