Medical History Form

Medications and Medical Alerts

Herbal Medication or Supplements (Please check all that apply)*

None
Anabolic steroids
Androstenedione
Black cohosh
Cat's claw
Chondroitin
Cranberry
Echinacea
Ephedra
Evening primrose
Feverfew
Fish oil
Flaxseed oil
Garlic
Gingko biloba
Ginseng
Glucosamine
Goldenseal
Green tea
Hawthorn
HCG
Horse chestnut
Human growth hormone
Kava
Licorice root
Mistletoe
Peppermint
Phentermine
Red Clover
Saw palmetto
St. John's Wort
Valerian
Vitamin A
Vitamin B
Vitamin C
Vitamin D
Vitamin E

Medications: (Please list all medications here. To upload a list of medications see below)

If you are not currently taking any medications, please write "no medications".

Upload Medications List Here

Drop files here or

Allergy List File Upload

Drug Allergies: (Please list all known allergies and reactions. If none, please write none in the first collumn.)

Allergy #1	Allergy #2	Allergy #3	Allergy #4	Allergy #5	Allergy #6

Smoking Status*

Alcohol Use:*

Medical Alerts: (Please check all that apply)*

Other Medical Alerts Not Listed

Review of Systems

Are you currently experiencing any of the following? Please selection yes or no.

Are you generally in good health?*

Do you have problems with bleeding?*

Do you have problems with healing?*

Do you have problems with scarring?*

Do you currently have a rash?*

Do you have any new skin lesions?*

Do you have any changing lesions?*

Are you pregnant or currently trying to get pregnant?*

Have you previously had a flu vaccine?*

Date of flu vaccine:

Have you previously had a pneumonia vaccine?*

Do you have a living will?

Power of Attorney/Advanced Directive

Do you have a Medical Power of Attorney (for yourself) or an Advanced Directive prepared? If so, please indicate who.

Have you been admitted to the hospital in the past 12 months?*

If you have been admitted to the hospital, please indicate why.

To your knowledge, do you have a history of a difficult airway during previous surgeries?*

Height*

Weight*

Thank You!

Thanks again for your time and effort to get the most up-to-date information to your provider. It is much appreciated. Please feel free to add any additional information, that you feel is important to your health record, in the box below.

Phone

This field is for validation purposes and should be left unchanged.

Summit Medical History Form

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Contact Information and Past Medical History

Medications and Medical Alerts

Review of Systems