Health History Form Δ Name (Please Print)(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Reason for visit(Required)Health HistoryCheck if Applicable(Required) Anemia/Bleeding problems Irregular heart rate Arthritis/Osteoporosis Kidney Disease Cancer Rheumatic Fever / Murmur Diabetes Stroke Breathing/Lung problems Thyroid Disease Epilepsy/Seizures Tuberculosis Fainting spells Ulcers Glaucoma/Cataracts HIV / AIDS Hepatitis Heart Disease/ Hypertension Heart Attack Irregular heart rate Kidney Disease Rheumatic Fever / Murmur Stroke Thyroid Disease Tuberculosis Ulcers HIV / AIDS Heart Disease/ Hypertension Other Other(Required)Have you ever had a blood transfusion?(Required) Yes No Drug/Alcohol HistoryDo you drink alcohol?(Required) Yes No If yes, when?(Required)Smoking HistoryDo you smoke?(Required) Yes No If yes, please indicatepacks per day(Required)for year(s)(Required)Did you quit smoking?(Required) Yes No Are you exposed to second-hand smoke?(Required) Yes No Are you taking any weight loss medication?(Required) Yes No If yes, which one?(Required)What other prescribed medications are you presently taking?(Required)What over the counter medications/herbal supplements/multivitamin/ADA or Aspirin Related products are you taking?(Required)Are you allergic to any medications?(Required)List any previous surgeries:
