Cary Office Click To Call
(919) 865-0700
1110 SE Cary Parkway Ste # 206
Cary, NC 27518, USA | Directions
Cornelius Office Click To Call
(704) 765-3150
20905 Torrence Chapel Rd #201
Cornelius, NC 28031, USA | Directions

Medical History

 Print blank form to fill by hand
Please note that it is important to fill in all the fields before submitting. Thank you.

*Last name :
*First name :
M.I :
Select the appropriate answer. If you don't know the answer please select 'Don't know'.
1.Are you under a physician’s care? YesNoDon't know
2.When was your last complete physical exam?
3.Physician’s Name :
Address : Street City
State
Zip
4.Are you taking any medication or substances? YesNoDon't know
5.Do you routinely take health related substances?(vitamin, herbal supplements, natural products)?YesNoDon't know
6.Are you allergic to any medications or substances? YesNoDon't know
7.Do you have any other allergies or hives?YesNoDon't know
8.Do you have any problems with penicillin, antibiotics, anesthetics or other medications?YesNoDon't know
9.Are you sensitive to any metals or latex?YesNoDon't know
10.Are you pregnant or suspect you may be?YesNoDon't know
11.Do you use any birth control medications?YesNoDon't know
12.Have you ever been treated for or been told you might have heart disease?YesNoDon't know
13.Do you have a pacemaker, an artificial heart valve, implant or been diagnosed with mitral valve prolapse?YesNoDon't know
14.Have you ever had rheumatic fever resulting in rheumatic heart disease?YesNoDon't know
15.Are you aware of any heart murmurs?YesNoDon't know
16.Do you have blood pressure problems?YesNoDon't know
17.Have you ever had a serious illness or major surgery? YesNoDon't know
18.Have you ever had radiation treatment or chemotherapy for a tumor, growth or other condition?YesNoDon't know
19.Do you have inflammatory diseases, such as arthritis or rheumatism?YesNoDon't know
20.Do you have any artificial joints or prostheses?YesNoDon't know
21.Do you have any blood disorders such as anemia, leukemia, etc.?YesNoDon't know
22.Have you ever bled excessively after being cut or injured?YesNoDon't know
23.Do you have any stomach problems?YesNoDon't know
24.Do you have any kidney problems?YesNoDon't know
25.Do you have any liver problems?YesNoDon't know
26.Are you diabetic?YesNoDon't know
27.Do you have fainting or dizzy spells?YesNoDon't know
28.Do you have asthma?YesNoDon't know
29.Do you have epilepsy or seizure disorders?YesNoDon't know
30.Do you or have you ever had a venereal disease?YesNoDon't know
31.Have you tested positive for HIV?YesNoDon't know
32.Do you have AIDS?YesNoDon't know
33.Have you had or do you test positive for Hepatitis?YesNoDon't know
34.Do you or have you had Tuburculosis (TB)?YesNoDon't know
35.Do you smoke, chew, use snuff or any other forms of tobacco?YesNoDon't know
36.Do you regularly consume more than one or two alcoholic beverages a day?YesNoDon't know
37.Have you had psychiatric treatment?YesNoDon't know
38.Do you habitually use controlled substances, legal or illegal?YesNoDon't know
39.Have you taken any of the following? Fenfluramine, fenfluramine combined with phentermine (fen-phen), Dexfenfluramine (redux), or other weight loss products?YesNoDon't know
40.Do you have any disease condition, or problem not listed?YesNoDon't know
41.Is there anything else we should know about your health that we have not covered in this form?
42.Would you like to speak to the Doctor privately about any problem?YesNoDon't know
*I certify that the above information is complete and accurate.
*Patient's / Guardian's signature :
 Date :