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 brieflyIncreased fatigue?* Yes No Please explain brieflyDifficulty with your vision?* Yes No Please explain brieflyDifficulty swallowing?* Yes No Please explain brieflyChest pains?* Yes No Please explain brieflySkin rashes for no apparent reason?* Yes No Please explain brieflyBruise easily or take blood thinners?* Yes No Please explain brieflyUse tobacco products?* Yes No Please explain brieflyConsume alcoholic beverages?* Yes No Please explain brieflyHeart arrhythmia?* Yes No Please explain brieflyHypertension?* Yes No Please explain brieflyHeart valve problems or pacemaker?* Yes No Please explain brieflyDo you have a defibrillator?* Yes No Asthma? Emphysema? Sleep apnea?* Yes No Please explain brieflyAcid reflux disease?* Yes No Please explain brieflyUrinary tract infections? Kidney stones?* Yes No Please explain brieflyCancer, including skin cancer?* Yes No Please explain brieflyArthritis: Rheumatoid/Osteo?* Yes No Please explain brieflyBleeding disorder?* Yes No Please explain brieflyDiabetes?* Yes No Please explain brieflyThyroid disease? Other Chronic conditions?* Yes No Please explain brieflyProblems with anesthesia?* Yes No Please explain brieflyFAMILY 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 DescribeDatePlease DescribeDatePlease DescribeDatePlease DescribeDatePlease DescribeDateDo you take any medications? (Including Supplements, Herbs, Aspirin) Yes No Current Medications: (including aspirin, herbs and supplements)Medication*Dose*X per day:*MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX per day:MedicationDoseX 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 #:*
