Medical History Form Template

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Medical History Form Template Powered By Docstoc
					             Confidential Medical History Forms

Allergies (scents, chemicals, foods, herbs etc...:_______________________________

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Are you currently being treated by other health care providers?__________________

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What Diagnosis have you received regarding your condition?___________________

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Surgeries (type & date):____________________________________________________

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Significant Trauma (auto accidents, falls, etc...):_______________________________

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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:_________________________________________________________

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DOCUMENT INFO
Description: This is a sample medical history form template.