Medical History



Yes No

1.
2.
3.
4.
5.

Yes No

1.
2.
3.
4.
5.

Yes No

Approximate YearReason
1.
2.
3.

Yes No

MedicationDoseFrequencyCondition begin treated/Symptoms
1.
2.
3.
4.
5.
6.
7.
8.

Yes No

MedicationType of Reaction

Yes No

RelativeAge of OnsetDisease
1.
2.
3.
4.
5.
6.
7.
8.


Cigarettes? Yes No
Chew? Yes No
Pipe? Yes No
Cigars? Yes No

Have you used tobacco products in the past? Yes No


Never Occasionally 1-2 drinks/day More than 2/day




Never Usually Always

Yes No











Yes No

Job/ProfessionHobbies/Interests

married single divorced other



1.
2.
3.




share: