COSMED MEDICAL HISTORY

Patient’s full name:
Date:
Edad / Age:
Gender:
Birthday:
YOUR GENERAL HEALTH IS OF THE MOST IMPORTANT TO US. PLEASE ANSWER THE FOLLOWING QUESTIONS CAREFULLY. THANK YOU.
General Health
List all the medications you are presently taking. Please include hormones, vitamins and birth control pills:
Do you suffer from any of the following?
Anemia
Heart Problems
A Heart Attack
Irregular Beats
High Blood Pressure
Chest Pain (Angina)
Abnormal Ekg
Rheumatic Heart Disease
Lungs
Shortness Of Breath
Asthma
Bronchitis
Emphysema
Liver Problems
Cancer
Do You Have A Family With History Of Heart Trouble?
Hepatitis
Hiv
Diabetes
Varicose Veins
Psychiatric Treatment
Cortisone Treatment
Drink Alcohol Beverages?
If Yes How Much Per Week?
Do You Smoke?
If Yes How Much Per Day?
Use Illicit Drugs
If Yes Specify:
Exercise Regularly?
Eye Problems
Kidney Problems
Others
Have you ever been hospitalized?
Please specify:
Surgery
Date
Anesthesia
Complications
Have you ever been seriously ill in the past year?
If yes, please explain:
If you are female, please answer these questions:
Are you pregnant?
Have you been pregnant?
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