Family History Past Medical History Relationship (check all that apply) (check all that apply) AIDS/HIV Infectious Mono ☐ ☐ ☐Allergies Allergies Kidney Disease ☐ ☐ ☐Alzheimer’s Anemia ☐ ☐Measles ☐Anemia (see below) ☐Cancer Arthritis ☐ ☐Migraines Type: Asthma ☐ ☐Dementia Back Pain ☐ ☐Neuropathy ☐Diabetes Bladder Infection ☐ ☐Osteoporosis ☐Epilepsy Blood Clots/ DVTs/ ☐ ☐Pneumonia ☐Glaucoma Pulmonary Embolus Bronchitis Disease ☐ ☐Heart Cancer ☐ ☐Pulmonary/ ☐Hypertension Type: Respiratory Disease Chicken Pox ☐ ☐Rheumatic ☐Parkinson’s Diabetes Fever ☐ ☐Scarlet ☐Stroke Diphtheria Apnea ☐ ☐Tuberculosis Eczema/ Hives Pox ☐ ☐Other: Epilepsy ☐ ☐Stroke ☐Other: Glaucoma Disease ☐ ☐Thyroid ☐Other Attack ☐ ☐Tuberculosis Hemorrhoids *Women Only ☐ ☐Transfusions Hepatitis Are you currently pregnant? ☐ ☐Ulcer ☐Yes ☐No ☐Sexually Hernia Are you currently breastfeeding? ☐ ☐Yes ☐No Transmitted Disease High Blood ☐ Cough Age of period: Pregnancies (#): ☐Whooping Pressure Date of Last period: Miscarriages (#): ☐Other: Other: Birth Control: Abortions (#): ☐ Current Medications (Please include over the counter medications, herbal supplements, vitamins, etc.) Medication: Dosage: Directions:
Past Medical History (check all that apply) Family History (check all that apply) Relationship ☐ AIDS/HIV ☐ Infectious Mono ☐Allergies ☐ Allergies ☐ Kidney Disease ☐Alzheimer’s ☐ Anemia ☐Measles ☐Anemia ☐ Arthritis ☐Migraines ☐Cancer (see below) Type: ☐ Asthma ☐Dementia ☐ Back Pain ☐Neuropathy ☐Diabetes ☐ Bladder Infection ☐Osteoporosis ☐Epilepsy ☐ Blood Clots/ DVTs/ Pulmonary Embolus ☐Pneumonia ☐Glaucoma ☐ Bronchitis ☐Heart Disease ☐ Cancer Type: ☐Pulmonary/ Respiratory Disease ☐Hypertension ☐ Chicken Pox ☐Rheumatic ☐Parkinson’s ☐ Diabetes ☐Scarlet Fever ☐Stroke ☐ Diphtheria Apnea ☐Tuberculosis ☐ Eczema/ Hives Pox ☐Other: ☐ Epilepsy ☐Stroke ☐Other: ☐ Glaucoma ☐Thyroid Disease ☐Other ☐ Attack ☐Tuberculosis ☐ Hemorrhoids ☐Transfusions *Women Only ☐ Hepatitis ☐Ulcer Are you currently pregnant? ☐Yes ☐No ☐ Hernia ☐Sexually Transmitted Disease Are you currently breastfeeding? ☐Yes ☐No ☐ High Blood Pressure ☐Whooping Cough Age of period: Pregnancies (#): ☐Other: Date of Last period: Miscarriages (#): ☐ Other: Birth Control: Abortions (#): Current Medications (Please include over the counter medications, herbal supplements, vitamins, etc.) Medication: Dosage: Directions: