Full Name*

Date of Birth*

Do you have a personal history of ANY of the following: (choose YES or NO)

Diabetes

Yes

No

High Blood Pressure

Yes

No

Heart Disease

Yes

No

If YES, explain

Lung Disease

Yes

No

Arthritis

Yes

No

Kidney Disease

Yes

No

Hepatitis

Yes

No

Tobacco Use

Yes

No

Drug/Narcotic Habit

Yes

No

Cancer (other than skin)

Yes

No

Type of Cancer:

Positive TB Test

Yes

No

Glaucoma

Yes

No

Pacemaker

Yes

No

Implanted Defibrillator

Yes

No

Artificial Heart Valve

Yes

No

Liver Disease

Yes

No

Artificial Joint

Yes

No

Bleeding Disorder

Yes

No

Alcohol Use

Yes

No

Diagnosed With HIV

Yes

No

Anxiety

Yes

No

Depression

Yes

No

Hormone Replacement

Yes

No

Do you have side affects from taking antibiotics such as nausea, yeast infections, or vomiting?

Yes

No

Please list any surgeries with in the last 5 years:

Do you have a personal history of skin cancer?

Yes

No

If yes, please explain when, what type & where:

Do you have a family history of skin cancer?

Yes

No

If yes, please list relationship to you:

List ALL medications you are presently taking. Include aspirin or any over-the-counter medications:

List medication allergies (including Latex)

Yes

No

If Yes, type which:

Patient Signature:

Reset

Date:

Medical History Form