Jeanne Marie Franck, MD

MEDICAL HISTORY

Patient Name: __________________________

Date: _________________ Reason for today's visit:

Are you allergic to any medications? Yes No If yes please list: ______________________________________ Do you have a latex allergy? Yes No

If yes what type of reaction? ___________________________________________________________________________ List all medications you are currently taking:

1.

2. 7. 3.

4. 8.

5.

6. 9.

History of diseases Do you have now, or have you ever had a disease or condition of:

Respiratory: Yes No

Cardiac:

Yes No Bronchitis

High blood pressure

Emphysema

Valve replacement

Asthma

Heart attack

Stroke

Other:

Heart murmur

Diabetes

Irregular heartbeat

Organ Transplant

Pacemaker

Arthritis

Stents

Artificial Joints

Heart bypass

Kidney

Mitral valve prolapse

Hepatitis HIV

Fainting

List any other disease(s) or condition(s) we should know about:

List surgical procedures you have had:

Please answer the following questions: 1. Have you ever had skin cancer? Yes No 4. (Women) Are you pregnant? Yes No

2. Do you smoke? Yes No

If yes expected date: ________________________

If yes how much? ______________ 3. Do you drink alcohol? Yes No 5. What is your occupation? ________________________ If yes how often? ______________