Adult Medical History Form

  • Medication NameDosageHow many times a dayDate started 
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  • PHARMACY INFORMATION

  • NameLocationPhone
  • Please check all that apply
  • ColonoscopyFlu ShotPneumoniaTetanus 
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  • Women Only

  • Menstrual CycleMammogramPAP Smear 
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  • Please list information for family members (parents, grandparents, and/or siblings) who have ever had any of the following
    High Blood PressureDiabetesHeart Disease, Stroke, Heart AttackCancer (specify type)CholesterolOtherN/A 
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  • Health Habits

  • Include how long you used, did you quit and if so, when
  • Include how long you used, did you quit and if so, when
    CaffeineTobaccoStreet Drugs 
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  • YearType of Surgery or HospitalizationLocationN/A 
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  • YearDetail of Illness/InjuryOutcome 
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  • To the best of my knowledge, the above information is complete and correct. I understand it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.