Health History Sheet Form 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 UseEmailThis field is for validation purposes and should be left unchanged. Δ
