Medical History Form

Current Basic Information
Medical Conditions
Medications
Allergies
Surgeries
Hand & Wrist Injuries
Health History
Signature
Complete

Basic Information

First Name

Middle Name

Last Name

Suffix

Dominant Hand

Right

Left

Other…

Height

feet

inches

Weight (lbs)

Primary Care Physician

Phone

Location / City

Medical Conditions

Medical Conditions
	Medical Conditions	Item weight

more items

List all medical conditions diagnosed by a physician (including those you take or do not take medication for)

Medications

List all medications you are taking (including vitamins/supplement, etc.)

Re-order	Medication Name	For Which Condition	Dose	Prescribing Physician	Weight	Operations
	Medication Name	For Which Condition	Dose	Prescribing Physician	Item weight

more items

Allergies

Allergies: please check “yes” or “no” to the following and list all you may have (or suspect you may have)

Medication Allergies

Re-order	Medications	List	Weight	Operations
	Medications Yes No	List	Item weight

Anesthetics Allergies

Re-order	Anesthetics	List	Weight	Operations
	Anesthetics Yes No	List	Item weight

Injection Allergies

Re-order	Injections	List	Weight	Operations
	Injections Yes No	List	Item weight

Latex Allergies

Re-order	Latex rubber	List	Weight	Operations
	Latex rubber Yes No	List	Item weight

Other

Surgeries

List all past surgeries

Re-order	Surgery	Date Performed	Surgeon	Location / City	Weight	Operations
	Surgery	Date Performed	Surgeon	Location / City	Item weight

more items

Hand & Wrist Injuries

List all past “hand and wrist” injuries:

Re-order	Injury	Date of Injury	Treating Physician	Location / City	Weight	Operations
	Injury	Date of Injury	Treating Physician	Location / City	Item weight

more items

Health History

Signature

Patient (or legal guardian) signature

Sign above

Basic Information

Medical Conditions

Medications

Allergies

Surgeries

Hand & Wrist Injuries

Health History

Signature

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