Medical Questionnaire
Desired procedure(s):
Physical Information
Gender?
Male
Female
Date of birth?
month
_
January
February
March
April
May
June
July
August
September
October
November
December
date
year
Heiqht?
Weiqht?
Emergency Contact Information
Name?
Daytime phone number?
Eveninq phone number?
Email address?
Fax?
Skype?
Physician Information
Name?
Address?
Phone number?
Email address?
Medical History Information
Do you have high blood pressure?
What is your blood pressure?
Date of last measure of your blood pressure?
Have you ever had surgery before?
If yes, what type?
Any complications?
Please type “Yes" or "No" for the following
Anemia?
Yes
No
Arthritis?
Yes
No
Asthma?
Yes
No
Jack problems?
Yes
No
Blood clots?
Yes
No
Blood disorders?
Yes
No
Bleeding problems?
Yes
No
Breathing problems?
Yes
No
Cancer?
Yes
No
Chest pains?
Yes
No
Colitis?
Yes
No
Depression?
Yes
No
Diabetes?
Yes
No
Ear problems?
Yes
No
Eye problems?
Yes
No
Epilepsy?
Yes
No
Heart problems?
Yes
No
Heart murmur?
Yes
No
Hepatitis?
Yes
No
High blood pressure?
Yes
No
Irregular heartbeat?
Yes
No
Kidney problems?
Yes
No
Migraine headaches?
Yes
No
Nervous breakdown?
Yes
No
Nose/throat problems?
Yes
No
Osteoporosis?
Yes
No
Pneumonia?
Yes
No
Psychiatric condition?
Yes
No
Rheumatic fever?
Yes
No
Seizures?
Yes
No
Shortness of breath?
Yes
No
Skin cancer?
Yes
No
Stomach problems?
Yes
No
Stroke?
Yes
No
Thyroid problems?
Yes
No
Tuberculosis?
Yes
No
Transfusion?
Yes
No
Are you pregnant?
Yes
No
Have you ever smoked?
Yes
No
Do you currently smoke?
Yes
No
If yes, how many years?
If yes, how many cigarettes/day?
Do you consume alcoholic beverages?
Yes
No
If yes, how many years?
If yes, how many per week?
Medication
Are you allergic to any medication?
Yes
No
If yes, give the name of the medication?
If yes, describe the allergic reaction?
Are you currently on medication?
Yes
No
If so, which medications?
Have you ever had problems with anesthesia?
Yes
No
Please describe any other issues that may need attention
