Health Check Form

Birth date
Marital Status SingleMarriedDivorcedWidowed
Occupation
Height
Weight
BMI Index
Address/City/State
Country
Phone

 

PAST MEDICAL HISTORY

Smoking: (If yes, state quantity):
Alcohol: (If yes, state quantity):
Other Substances:(If yes, specify)
Date of last menstrual period:
Prescriptions/Medications:
Number of pregnancies:
Number of live births:
Last childbirth (Date):
Method of birth control: (Specify)
If menopausal, date of onset:
Drug Use:
YesNo
Drug allergies/adverse drug reaction:
YesNo
Reaction to Anaesthesia:
YesNo
Blood Transfusion:
YesNo
Sexually Transmitted Disease:
YesNo
HIV:
YesNo
Hepatitis:
YesNo
Breast Feeding:
YesNo
Hereditary health concerns:
YesNo
 
Diabet:

YesNo

Insulin:
YesNo

Oral antidiabetic pills:
YesNo

 
Blood Pressure:
YesNo
Cholesterol:
YesNo
Cancer:
YesNo
Kidney Disease:
YesNo
Epilepsy or Seizures:
YesNo
Anemia:
YesNo
Arthritis:
YesNo
Asthma/Emphysema:
YesNo
Gallbladder Disease:
YesNo
Cancer:
YesNo
Difficulty in Swallowing/Stroke:
YesNo
Joint Pain:
YesNo
Constipation or Diarrhea:
YesNo
Abnormal Vaginal Bleeding:
YesNo
Swollen Glands:
YesNo
Anxiety:
YesNo
Pelvic Pain:
YesNo
Reflux:
YesNo
Chest Pain:
YesNo
Shortness of Breath:
YesNo
Difficulty Sleeping/Apnea:
YesNo
Nausea:
YesNo
Dizziness:
YesNo
Rectal Bleeding:
YesNo
Burning w/Urination:
YesNo
Hot Flashes:
YesNo
Burning w/Urination:
YesNo
Heart Disease
Murmur:
YesNo
Cardiac failure:
YesNo
Rhythm disturbances:
YesNo

 

Surgical history(State any surgical procedure):
Date:
Notes:

Please fill in all space and submit.

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