Health History

Name

First Name

Last Name

Date of Birth

YYYY

1. Please list MEDICATIONS, both prescription and non-prescription. Include strength/dosage and frequency of each medication. (ie. 20mg, 1 tab daily):

2. Please list ALLERGIES to medications, food and other. Also, describe type of reaction:

3. Please list SURGERIES and dates:

4. Please list other hospitalizations, major illnesses, injuries and dates:

5. Date of Last Tetanus Vaccine:

YYYY

Date of Last Pneumonia Vaccine:

YYYY

Date of Last Influenza Vaccine:

YYYY

Date of Last Zostavax (Shingles) Vaccine:

YYYY

6. Exercise History (Exercise Type and Frequency):

7. Do you drink alcoholic beverages:

Yes

If yes, list as accurately as possible how many cans of beer, shots of whiskey or glasses of wine you drink per week:

8. Do you smoke/chew tobacco?

Yes

If yes, how many packs per day? How many years?

9. Do you use or abuse other substances or drugs?

Yes

Family Medical History

Please list family members (parents, grandparents, uncles, aunts, brother, sisters, children) who have the following:

High Blood Pressure:

Heart Attack:

Heart Stents:

Diabetes:

Stroke:

Cancer (include type if known):

Kidney Disease:

Asthma:

Thyroid:

Mental Disorder (include type if known):

Other (illnesses not mentioned above):

Is your mother living? If not, age and cause of death?

Is your father living? If not, age and cause of death?