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Description
This is a sample medical history form template.
Document Sample
Confidential Medical History Forms Allergies (scents, chemicals, foods, herbs etc...:_______________________________ ________________________________________________________________________ ________________________________________________________________________ Are you currently being treated by other health care providers?__________________ ________________________________________________________________________ ________________________________________________________________________ What Diagnosis have you received regarding your condition?___________________ ________________________________________________________________________ ________________________________________________________________________ Surgeries (type & date):____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Significant Trauma (auto accidents, falls, etc...):_______________________________ ________________________________________________________________________ ________________________________________________________________________ Do you have a pacemaker?___________________ Do you have a contagious skin disorder?______________________________ Please circle all that apply to you: Cancer Diabetes Depression Stroke/heart disease Itching Fever Epilepsy Concussion Parasites Numbness/tingling Hives Anxiety Thyroid Disease Hepatitis Athlete's Foot HIV Positive Seizures High Blood Pressure Chronic Fatigue contagious skin disorder Insomnia Eczema Asthma Rosacea/sensitive skin Acne Edema Pregnant Rashes Fatigue Disc Herniation knee pain hip pain shoulder pain back pain jaw click Sciatica TMJ joint swelling joint pain Frozen Shoulder hand pain wrist pain Fibromyalgia Carpel Tunnel Syndrome Arthritis stiff neck Other problems:_________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
