Comprehensive Medical History: Rule Out Form
Courtesy of Dr. Katherine Day


Patient's name:

Gender:        Age:        DOB:        Race:        Weight:        Height:       

Address:

 

Telephone:              SSN#:       

On the basis of patient self-report, the following medication conditions have been confirmed or excluded:
Past Present Uncertain None
Drug allergies        
Chemical sensitivities        
Heart disease        
Hypertension        
Diabetes Type I        
Diabetes Type II        
Endocrine disorders        
Renal disease        
Liver disease        
Neurological disorders        
Malignancies        
Chemical dependencies        

Other relevant history:

 

 

Please explain any above category not marked "NONE":

 

 

 

 

All of the above information has been verified by the patient's treating physician or by consultation with another physician who has examined this patient:    YES    NO

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