Medical History Questionnaire

Company Name:

First Name:

Last Name:

Date of Birth (MM/DD/YY):

Height:

Weight:

Condition:

Treatment Dates:

Please provide further details of this condition:

What were your symptoms before diagnosis and treatment?

Name of Treating Physician:

City of Treating Physician:

State of Treating Physician:

Please list any tests/studies completed or recommended including dates and results:

Describe any treatment, therapy or surgery performed including dates:

Have you been hospitalized or missed work for this condition?

Yes   No

If so, how long?

When?

Any residual disability?

Yes   No   N/A

Degree of Recovery:

What is your current status?

Medications:
(name, dosage and dates prescribed)

Any follow-up treatment or surgery recommended? If so, please list including dates.

When was your last office visit?

When is your next office visit?

Have you used any tobacco products in the last 12 months?

Yes   No

If so, what type?

How often?

By clicking on the SUBMIT button below you are attesting that the above statements are true and realize that the answers to these questions will be used to determine health coverage.

Please print a copy of this completed form for your records before hitting the SUBMIT button.