JotForm

General Patient Information
Patient Gender *
Patient Name *

First Name Last Name
Patient Birth Date *

Month Day Year
Patient Height (cm's) *
Patient Weight (kg's) *
Patient E-Mail *
Reason for seeing the doctor: *
Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)

Anemia Asthma Arthritis Cancer Gout Diabetes Emotional Disorder Epilepsy Seizures Fainting Spells Gallstones Heart Disease Heart Attack Rheumatic Fever High Blood Pressure Digestive Problems Ulcerative Colitis Ulcer Disease Hepatitis Kidney Disease Liver Disease Sleep Apnea Use a C-PAP machine Thyroid Problems Tuberculosis Venereal Disease Neurological Disorders Bleeding Disorders Lung Disease Emphysema
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications
Healthy & Unhealthy Habits
Exercise

Never 1-2 days 3-4 days 5+ days
Eating following a diet

I have a loose diet I have a strict diet I don't have a diet plan
Alcohol Consumption

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day
Caffeine Consumption

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day
Do you smoke?

No 0-1 pack/day 1-2 packs/day 2+ packs/day
Include other comments regarding your Medical History
Should be Empty:

General Patient Information