GARM Patient History Form

    Sex
    MaleFemale

    Current Medications

    Drug Allergies
    YesNo

    Are you Allergic to Latex
    YesNo

    Please list any medications that you are now taking. Include non-prescription medications, vitamins, and supplements.
    Include name, dose, start date.

    Past Medical History

    Do you now or have you ever had:
    DiabetesHeart murmurCrohn's diseaseHigh blood pressurePneumoniaColitisHigh cholesterolPulmonary embolismJaundiceHypothyroidismHyperthyroidismAsthmaHepatitisGoiterEmphysemaHIV/AIDSStrokeStomach or peptic ulcer problemsAnemiaLeukemiaEpilepsy (seizures)Rheumatic feverPsoriasisCataractsTuberculosisAngina/Chest PainKidney diseaseMalariaHeart problemsKidney stonesDengue

    Other medical conditions

    Family History
    Father
    List age, health & psychiatric, if deceased age at death and cause.

    Mother
    List age, health & psychiatric, if deceased age at death and cause.

    Siblings
    List age, health & psychiatric, if deceased age at death and cause.

    Children
    List age, health & psychiatric, if deceased age at death and cause.

    Any Additional Info:

    Surgeries / Hospitalizations
    Please list surgeries and/or hospitalizations: