Dr Ralph Stanford - Form for patient's medical history

MEDICAL HISTORY FORM

Please print a copy of this form so you can fill it out and bring it with you when you come in for your consultation with Dr Stanford.

Full Name:
Weight:		Height:

Please circle YES if you have or NO if you do not have each of the medical conditions listed.

ANGINA (heart pain)	YES	NO
HYPERTENSION (high blood pressure)	YES	NO
DIABETES (high blood sugar)	YES	NO
RENAL DISEASE (kidney disease)	YES	NO
RESPIRATORY ILLNESS (lung problems)	YES	NO
BLEEDING DISORDER	YES	NO
HEPATITIS (liver virus or disease)	YES	NO
HIV/AIDS	YES	NO
CANCER	YES	NO
CHICKEN POX or SHINGLES	YES	NO
RECENT VIRAL ILLNESS (flu-like illness)	YES	NO

If you answer YES for any of the above, please describe your treatment.

Please circle YES if you have or NO if you do not have a past-history of each of the following?

DEEP VEIN THROMBOSIS (blood clots in the leg)	YES	NO
PULMONARY EMBOLISM (blood clots in the lung)	YES	NO
HEART ATTACKS	YES	NO
DIFFICULTIES WITH ANAESTHESIA	YES	NO

If you answer YES for any of the above, please provide details.

What medications are you taking now?

List any operations you have had.

Did you suffer any major complications from past operations?

If you have a condition not listed above, please describe.

Are you allergic to any medications? YES / NO

If YES, please specify...

HABITS

Smoking:	Never
	Number each day.........	OR, when did you quit?.........

FEMALE HISTORY

Birth control pills	YES	NO
Hormone replacement treatment (HRT)	YES	NO

Signed: ..................................................................... Date: ...............

Please remember to bring this form with you when you have your appointment with Dr Stanford.