LIFESTYLE Family Healthcare - Past Medical History Form

PAST MEDICAL HISTORY FORM

Name: ______________________________

Birthdate: ______________________________

Medications/Allergies:

Are you taking any prescriptionmedications presently? □ Yes □ No

If yes, please list them below:

Medication Name: Howmany times/day? Why are you takingthis?

Are you taking any over-the-countermedications presently? □ Yes □ No

If yes, please list them below:

Medication Name: Howmany times/day? Why are you takingthis?

Are you allergic to any medicationsor other substances? □ Yes □ No

If yes, please list them below:

Medication Name: Whatkind of reaction did it cause?

Hospitalizations:

Please list all of your prior hospitalizations

If yes, please list them below:

Illness/Operation: Where: Year:

Your Health History:

Please check off if you have ever hadany of the following: