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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

Source: http://www.sivein.com/downloads/patient-medical-history.pdf