What is a Medical History Form?
When to use a Medical History Form:
- You would like to create a file for a new patient.
- You would like to have a record of past diagnoses.
- You would like to enable contract tracing.
This form is made and distributed by of , , . All answers in this form will be kept confidential.
What is the reason for your visit?
|Do you have any allergies?||Yes||No|
If yes, please list:
Past Medical History
Check the boxes if you currently experience or have experienced any of the following:
☐ Heart Problems
☐ Heart Surgery
☐ High Blood Pressure
☐ Liver Disease
☐ Kidney Disease
☐ Thyroid Disease