Personal Medical History & Medication Form - Health in 30

[Pages:2]Personal Medical History & Medication Form

Last Name _____________________________________________ First Name____________________________________________ DOB _____________ Marital Status____________________________________ Religion ________________________________________ Male Female Address ____________________________________________________________________________ State __________________ Zip Code _______________ Phone (Home) ___________________________________ (Work) ____________________________ (Cell) ___________________________________ ALLERGIES to Medications: YES NO If Yes, list allergies _________________________________________________________________________________ ALLERGIES to Foods, Man-Made Materials, etc.: YES NO If Yes, list allergies ________________________________________________ Insurance Co.__________________________________________________________ Policy No.____________________________________________________________________________________________ Emergency Contact: Name ____________________________________________________________Relationship __________________________________ Phone (Home) ___________________________________ (Work) ____________________________ (Cell) ___________________________________ Who Do You Grant Permission to Speak on Your Behalf? (If Different Than Emergency Contact) Emergency Contact: Name ____________________________________________________________Relationship __________________________________ Phone (Home) ___________________________________ (Work) ____________________________ (Cell) ___________________________________ Physicians (Health Care Providers(s)): Name __________________________________________________Specialty__________________________________Phone ____________________________ Name __________________________________________________Specialty__________________________________Phone ____________________________

Present Medical History: _______________________________________________________________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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Past Medical History (including place and dates of hospitalizations): __________________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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Medications: (Prescription, Supplements, Vitamins, Herbal Supplements, Over-the-Counter)

Pharmacy Name & Phone Number ____________________________________________________________________________________________________

Name:

Dose (# milligrams, etc.)

No. of Times Day:

Route (By mouth, injection etc):

_____________________________________ ______________________________ ______________________________ __________________________________

_____________________________________ ______________________________ ______________________________ __________________________________

_____________________________________ ______________________________ ______________________________ __________________________________

_____________________________________ ______________________________ ______________________________ __________________________________

_____________________________________ ______________________________ ______________________________ __________________________________

_____________________________________ ______________________________ ______________________________ __________________________________

_____________________________________ ______________________________ ______________________________ __________________________________

_____________________________________ ______________________________ ______________________________ __________________________________

_____________________________________ ______________________________ ______________________________ __________________________________

_____________________________________ ______________________________ ______________________________ __________________________________

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