Heal 360 Medical History Form

Patient Name*

Date

Are you allergic to any MEDICATIONS? (Yes or No)

Past Medical History

Do you have now, or have you ever had diseases or conditions of: Please select all that apply (Bronchitis / Asthma, Emphysema, Kidney, Chronic Cough, Morning Cough, Hepatitis or Yellow Skin, High Blood Pressure, Chest Pain, Heart Attack, Heart Murmur, Irregular Heart Beat, Artificial Joint, Diabetes, Thyroid Disease, Bleed Easily,

Bladder, Stomach, Glaucoma, Arthritis / Joint Deformation, Convulsions, Epilepsy, Seizures, Fainting, Pacemaker, Exposure to HIV / AIDS)

Please list which of the above apply (or write None)

Family History

Does anyone in your IMMIDIATE family have any Chronic medical condition, such as: Bleeding disorders, Cancer, High Blood pressure or other condition? (Yes or No)

Surgical History

Please list any past surgeries and dates (or write None)

Social History

Do you drink Alcohol? (Yes or No)

Do you use IV drugs? (Yes or No)

Do you smoke? (Yes or No)

[Women] Are you pregnant? (Yes or No)

Please do not submit any Protected Health Information (PHI).

Submit