MEDICAL HISTORY QUESTIONNAIRE Last Name: First Name: Middle Name: Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?   Yes    No  Please List: Do you take any prescribed medication on a permanent or semi-permanent basis (steroids, anti-inflammatories, antibiotics, insulin, etc.)?   Yes    No  Please List: Do you have any Family Medical History we need to know about for today’s visit?   Yes    No  (list any family history) - (“Mother, Father, Sisters or Brothers”) Have you ever been treated for diabetes?   Yes    No  (list any medication and treating physician) Do you currently have or have you ever had high blood pressure?   Yes    No  (list any medication) Have you had any surgery in the past?   Yes    No  (please list any past surgery) Are you currently taking any Aspirin or Blood Thinner?   Yes    No  Are you currently a Dialysis Patient?   Yes    No  Unit: Phone: Contact: Do you have any other conditions that we should be aware of (i.e., ulcers, pregnancy, etc.)?   Yes    No  (Specify and give details) **Please use this area if you need any additional space**