Medical History Form LocationACMSPCMSLDSEmail Date(Required) MM slash DD slash YYYY First Name Middle Last Name Date of Birth MM slash DD slash YYYY For the following questions, choose yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.1. Are you in good health? Yes No 2. Has there been any change in your general health within the last year? Yes No 3. My last physical examination was on 4. Are you now under the care of a physician? Yes No What is the condition being treated? 5. The name and address of my physician(s) is 6. Do you receive regular dental care? Yes No 7. My last dental examination was on 8. The name and address of my dentist is 9. Have you had any serious illness? Yes No What and when? 10. Are you taking any medicine(s) including non-prescription medicine? Yes No What medicine(s) are you taking? 11. Do you have or have you had any of the following diseases or problems?a. Damaged heart valves or artificial heart valves, including heart murmur or rheumatic heart disease Yes No b. Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occluusion, high blood pressure, arteriosclerosis, stroke, high cholesterol) Yes No c. Do you have a cardiac pacemaker? Yes No d. High cholesterol? Yes No e. Allergy Yes No f. Asthma or hay fever Yes No g. Fainting spells or seizures Yes No h. Persistent diarrhea or recent weight loss Yes No i. Diabetes Yes No Insulin Dependent Yes No j. Hepatitis, jaundice or liver disease Yes No k. AIDS or HIV infection Yes No l. Thyroid problems Yes No m. Respiratory problems, emphysema, bronchitis, pneumonia, etc. Yes No n. Arthritis or painful swollen joints Yes No o. Stomach ulcer or hyperacidity Yes No p. Kidney Trouble Yes No q. Tuberculosis Yes No r. Persistent cough or cough that produces blood Yes No s. Sexually Transmitted Diseasesa. Gonorrhea Yes No b. Syphilis Yes No c. Herpes Yes No d. Other Yes No t. Epilespy, seizures, fits or other nurological disease Yes No u. Problems with mental health Yes No v. Cancer Yes No w. Problems of the immune system Yes No 12. Have you had abnormal bleeding? Yes No a. Have you ever required a blood transfusion? Yes No 13. Do you have any blood disorder such as anemia? Yes No Sickle Cell Disease Yes No 14. Have you ever had any treament for a tumor or growth? Yes No 15. Are you allergic or have you had a reaction to any drug or medication? Yes No If so, what? 16. Do you have any food allergies? Yes No If so, what? 17. Do you have any religious beliefs or cultural concerns that may affect your treament? Yes No Please explain 18. Do you have any disease, condition or problem not listed above? Yes No Please explain 19. Please list any Surgeries Performed and Dates20. Please list any Blood Test Performed, Type and Dates21. Please list any other tests performed, Type and Dates22. Colonoscopy Yes No Please list when and your physician. Social History23. Smoke or other tobacco uses Yes No Packs per day # of years 24. Alcohol Yes No Type Amount 25. Drugs Yes No Type 26. Vaping Yes No Type Occupation Employment History28. Current or recent employment in any of these occupations Steel/Iron/Sheet Metal Painter Roofer Firefighter Barber/Hairdresser Bus/Truck Driver Plumber/Pipefitter Carpentry/Construction Aircraft/Aerospace Industry Coke Production Shipyard/Dockyard Welding Boilermaker Electrician Bricklayer 29. Have you traveled outside the country recently? Yes No When and Where? Learning Needs30. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy? Always Often Sometimes Rarely Never If you need help, do you have someone to help you? Yes No If so, who? Women31. Are you pregnant? Yes No # of Pregnancies# of live births32. Do you have any problems associated with your menstrual period? Yes No Last menstrual period 33. Mammogram Yes No When/Where 34. Pap Smear Yes No When/Where Family HistoryHigh Cholesterol Father Mother Father's Parents Mother's Parents Siblings Children Heart Disease Father Mother Father's Parents Mother's Parents Siblings Children High blood pressure Father Mother Father's Parents Mother's Parents Siblings Children Stroke Father Mother Father's Parents Mother's Parents Siblings Children Cancer Father Mother Father's Parents Mother's Parents Siblings Children Glaucoma Father Mother Father's Parents Mother's Parents Siblings Children Diabetes Father Mother Father's Parents Mother's Parents Siblings Children Epilepsy/Convulsions Father Mother Father's Parents Mother's Parents Siblings Children Bleeding Disorder Father Mother Father's Parents Mother's Parents Siblings Children Kidney disease Father Mother Father's Parents Mother's Parents Siblings Children Thyroid disease Father Mother Father's Parents Mother's Parents Siblings Children Mental Illness Father Mother Father's Parents Mother's Parents Siblings Children Osteoporosis Father Mother Father's Parents Mother's Parents Siblings Children Asthma Father Mother Father's Parents Mother's Parents Siblings Children Alcoholism Father Mother Father's Parents Mother's Parents Siblings Children I certify that I have read and understand the above and have provided complete information to the best of my knowledge.ACMS Representative Signature of Patient EmailThis field is for validation purposes and should be left unchanged.
