Health History "*" indicates required fields First Name* Last Name* Email* Weight*Height Feet*Height Inches*Have you experienced?Sudden onset of weight loss or gain?* Yes No Please explain briefly Increased fatigue?* Yes No Please explain briefly Difficulty with your vision?* Yes No Please explain briefly Difficulty swallowing?* Yes No Please explain briefly Chest pains?* Yes No Please explain briefly Skin rashes for no apparent reason?* Yes No Please explain briefly Bruise easily or take blood thinners?* Yes No Please explain briefly Use tobacco products?* Yes No Please explain briefly Consume alcoholic beverages?* Yes No Please explain briefly Heart arrhythmia?* Yes No Please explain briefly Hypertension?* Yes No Please explain briefly Heart valve problems or pacemaker?* Yes No Please explain briefly Do you have a defibrillator?* Yes No Asthma? Emphysema? Sleep apnea?* Yes No Please explain briefly Acid reflux disease?* Yes No Please explain briefly Urinary tract infections? Kidney stones?* Yes No Please explain briefly Cancer, including skin cancer?* Yes No Please explain briefly Arthritis: Rheumatoid/Osteo?* Yes No Please explain briefly Bleeding disorder?* Yes No Please explain briefly Diabetes?* Yes No Please explain briefly Thyroid disease? Other Chronic conditions?* Yes No Please explain briefly Problems with anesthesia?* Yes No Please explain briefly FAMILY HISTORY: Does any member of your immediate family have? If so, who?Arthritis? Glaucoma? Cancer? Macular degeneration? Heart disease? Retinal detachment? High Blood Pressure? Stroke/TIA? Diabetes? Anesthesia complications? Past Surgeries, Trauma or Hospitalizations: Yes No Please Describe Date Please Describe Date Please Describe Date Please Describe Date Please Describe Date Do you take any medications? (Including Supplements, Herbs, Aspirin) Yes No Current Medications: (including aspirin, herbs and supplements)Medication* Dose* X per day:* Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Medication Dose X per day: Do You Have Any Known Drug Allergies?* Yes No Allergies or sensitivity to medicines:Drug:* Reaction:* Drug: Reaction: Drug: Reaction: Drug: Reaction: PharmacyPreferred Pharmacy:* Phone #:*
