MEDICAL HISTORY FORM TEMPLATE

PATIENT NAME	DATE of LAST UPDATE	MEDICAL HISTORY FORM
CURRENT PHYSICIAN NAME	PHONE
CURRENT PHARMACY NAME	PHONE
CURRENT and PAST MEDICATIONS
MEDICATION NAME	DOSAGE	FREQ.	PHYSICIAN	START	END DATE	PURPOSE
SURGICAL PROCEDURES
PROCEDURE	PHYSICIAN	HOSPITAL	DATE	NOTES
MAJOR ILLNESSES
ILLNESS	START	END DATE	PHYSICIAN	TREATMENT NOTES
VACCINATIONS
NAME	DATE	NAME	DATE
TETANUS	MENINGITIS
INFLUENZA VACCINE	YELLOW FEVER
ZOSTAVAX	POLIO
OTHER:	OTHER:

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