Personal Medical History

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PERSONAL MEDICAL HISTORY

Name: __________________________________________Birth date: ________________

Telephone number: ___________________________ Mobile: ________________________

Email address: ____________________________________________________________

Diagnoses/Past Procedures/Physical Exam (include date/yr):

1.       _____________________________________________________________________

2.       _____________________________________________________________________

3.       _____________________________________________________________________

4.       _____________________________________________________________________

5.       _____________________________________________________________________

Drug sensitivities and allergies:

1.       ______________________________________________________________________

2.       ______________________________________________________________________

3.       ______________________________________________________________________

Family History: important medical problems:

1.       _______________________________________________________________________

2.       _______________________________________________________________________

3.       _______________________________________________________________________

4.       _______________________________________________________________________

5.       _______________________________________________________________________

Date of last physical: ________________                           Date of last tetanus shot: __________________

Date of last dental exam: _____________                         

Have you ever been told you have one of the following?

Lung disorder                                                    yes         no                           Diabetes                              yes         no

High blood pressure                                       yes         no                            Arthritis                                yes         no

Heart trouble                                                     yes         no                           Hepatitis                              yes         no

Nervous disorder                                             yes         no                            Malaria                                 yes         no

Disease or digestive tract disorders             yes         no                            Disease of the kidney        yes         no

Any vision of hearing disorders                  yes         no                              Any form of cancer         yes         no

 Date:______________________________________

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