Patient Information
Personal History
MarriedSingleWidowedDivorced
Medical History
The thoroughness of this medical history is designed for your safety, and your complete answers will assist us in treating you with consideration for your special needs.
Please check YES or NO.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
DietOral MedicationInjections
YesNo
YesNo
YesNo
Type A Infectious (Food) Type B Serum (Blood)
Type C (non-A, non-B) Unknown
YesNo
YesNo
Anemia AIDS or HIV positive test Leukemia Venereal disease
Other:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Rheumatoid Arthritis Gout/Gouty Arthritis Osteoarthritis Other
YesNo
YesNo
YesNo
YesNo
Right eyeLeft eyeBoth eyes
Have you gained or lost weight within the last year?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Questions 35-36 are For Women Only
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Please indicate if you are taking any of the following medications:
Alcohol
Tobacco
YesNo
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