Microsoft word - new aug2009 patient medical history
Date of Birth :________________________
Today’s Date:________________________
Medical History Do you have any of the following medical conditions? Please check all that apply
Please List any additional medical conditions:___________________________________ ________________________________________________________________________ Are you taking any of the following medications? Please check all that apply
Please List any additional medications:_____________________________________________ ____________________________________________________________________________
Are you taking Estrogen/Progesterone/Birth Control Pills now?.
Latex………. Local Anesthetics?
Are you allergic to any other Medications?________________________________________
Do you require antibiotics before surgery or dental work?.
Please List any Surgeries you have had____________________________________________ ____________________________________________________________________________
Are you currently pregnant, trying to get pregnant, or planning a pregnancy?
Do you smoke tobacoo?.
If Yes how long________________________
What kind of work do you do?___________________________________________________ Who Is your Primary Doctor____________________________________________________ Additional Notes ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Patient Signature__________________________________ Date________________________ Southern Illinois Vein Center 3106 W. Outer Dr. Ste 100 Marion, Illinois Ofc… 618-998-8346 Fax…618-997-3942
PERSONAL DETAILS Surname: _________________________________ Given Names:___________________________ Address:_________________________________________________________________________ _________________________________________________Postcode:_______________________ Telephone No: (Home) ________________________ (Bus): _______________________________ Mobile No:____________________________ D
Date of Birth :________________________
Today’s Date:________________________