Personal Medical History & Medication Form
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: _______________________________________________________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Past Medical History (including place and dates of hospitalizations): __________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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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