Medical History Form
Medical History Form
Full Name:
Age:
Gender:
Contact Number:
Email Address:
Check the Conditions that apply to you or any member of your immediate relatives:
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Yes |
No |
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Asthma |
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Cardiac Disease |
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Hypertension |
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Epilepsy |
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Cancer |
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Diabetes |
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Psychiatric Disorder |
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Other:
Check the symptoms that you’re currently experiencing:
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Chest pain |
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Hematology |
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Gastrointestinal |
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Musculoskeletal |
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Respiratory |
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Lymphatic |
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Genitourinary |
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Cardiac disease |
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Neurological |
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Weight Gain |
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Cardiovascular |
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Psychiatric |
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Weight Loss |
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Other:
Are you currently taking any medications? Yes ☐ No☐
If yes kindly list them:
Do you have any medical allergies? Yes ☐ No☐
If yes kindly list them:
Do you use any tobacco, or have you ever used them? Yes ☐ No☐
If yes kindly list them:
Do you use any kind of illegal drugs or have ever used them? Yes ☐ No☐
If yes kindly list them:
How Often do you consume alcohol? Daily ☐ Weekly☐ Monthly☐ Occasionally☐ Never ☐
