Medical History Form CHECK THE BOX IF YOU HAVE HAD ANY OF THE FOLLOWING: . . Diabetes High Blood Pressure Circulatory Problems Arthritis Stroke Kidney Disease Rheumatic Fever Migraines/ Headaches Lung Disease . . Neurological Problems Heart Disease/ Pacemaker Liver Disease Heart Murmur Osteoporosis Epilepsy/ Seizures Cancer Fractures Metal Implants Other: Please explain List any significant hospitalizations and surgical procedures/reasons/dates: Do you have any medication allergies? 4 + 8 = Submit © Copyright 2021 Graceland Psychiatry