Health History Sheet Form "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Name (Please Print):*Email* Primary Care Doctor (PCP):Pharmacy name:Pharmacy address:Registration number:Presenting problem or reason for visit:*Check if applicable: Anemia / Bleeding Problems Arthritis / Osteoporosis Cancer Diabetes Breathing / Lung Problems Epilepsy / Seizures Fainting Spells Glaucoma / Cataracts Hepatitis Heart Attack Irregular Heart Rate Kidney Disease Rheumatic Fever / Murmur Stroke Thyroid Disease Tuberculosis Ulcers HIV / AIDS Heart Disease / Hypertension Have you ever had a blood transfusion? (select one)* Yes No Do You Drink Any Alcoholic Beverages? (select one)* Yes No Do You Smoke? (select one)* Yes No If yes, how long?*How Often?*Have You Ever Taken Accutane (an acne medication)? (select one)* Yes No Have You Ever Taken Viagra? (select one)* Yes No What Medications Are You Presently Taking?*What Over The Counter Medications/Herbal Supplements/Multi Vitamins/ASA or Aspirin Related Products Are You Taking?*Do You Have Any Allergies To Medications?*List Any Previous Surgeries:*Last Pregnancy:*Last Mammogram:*SIGNATURE:Date:* MM slash DD slash YYYY By submitting this form I agree to the Terms of Use Δ
