Medical History Form More Forms New Patient PackageDemographicMedical HistoryMedications ListFinancial PolicyHIPAA ConsentNotice of Privacy PracticesRecords Release Medical History Date Name* First Middle Last Medical Conditions/Past Medical HistoryDo you have, or have you had, any of the following? Please switch to YES for any that apply.High blood pressure?YesNoStroke?YesNoMultiple Sclerosis?YesNoDiabetes?YesNoDiabetes TypeType IType IITIA?YesNoEpilepsy/ Seizures?YesNoImbalance?YesNoHigh cholesterol?YesNoHeart Disease?YesNoNeuropathy?YesNoOther:List any other medical conditions not listed.Cancer?YesNoTypeYear Diagnosed:Treatment:Any Previous Surgeries?YesNoList all previous surgeries Type of surgery Approximaly Date (MM/YYYY)   Edit Delete There are no Entries. Add New Surgery Entry Have you been admitted to the hospital/ ER in the past year?YesNoHospitalization: Date Hospital Name Reason   Edit Delete There are no Entries. Add Entry Family History:Father:*LivingDeceasedCurrent agePlease enter a number from 1 to 110.deceased, at agePlease enter a number from 1 to 110.Cause of death:Mother:*LivingDeceasedCurrent agePlease enter a number from 1 to 110.deceased, at agePlease enter a number from 1 to 110.Cause of death:Brother(s)*YesNoNumber living:Please enter a number from 0 to 30.Number Deceased:Please enter a number from 0 to 30.Cause of death:Sister(s)*YesNoNumber living:Please enter a number from 0 to 30.Number Deceased:Please enter a number from 0 to 30.Cause of death:Children*YesNoChildren List Gender Age cause of Death   Edit Delete There are no Entries. Add Children Marital Status:*SingleMarriedDivorcedWidowedSpouse’s Name:Spouse’s Date of Birth Social History:Are you a current or former smoker?*YesNoHow many cigarettes a day do you smoke?How soon after you wake up do you smoke your first cigarette?Are you interested in quitting?YesNoDo you have little or no interest in doing things?*YesNoHave you been feeling down depressed or hopeless?*YesNoHave you used drugs other than for medical reasons in the past 12 months?*YesNoIf so, please listDo you currently drink alcoholic beverages?*YesNoHow many per day/week/month/yearDo you drink caffeinated beverages?*YesNoHow many cups per dayHighest level of education*High SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOtherPrefer Not to AnswerOccupation or Prior occupation if retired:*Present Illness:Briefly describe your present symptoms:*Approximate date when symptoms began:*Previous treatment for this problem, if any