Randy Morton, M.D.
3209 North Fourth Street, Suite 300
Longview, Texas 75605 (903) 753-7205

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HEALTH HISTORY

Patient Name:_________________________________Date:__________________

Date of current illness/injury:_____________________________________________

Drug allergies:_____________________________

List all previous surgeries:________________________ Date:_______________

________________________ Date:_______________

________________________ Date:_______________

________________________ Date:_______________

________________________ Date:_______________
Do you take any type of anticoagulant, blood thinner or aspirin containing products?
____Yes ____No

List all current medications and dosages: ______________________________________________

_______________________________________________________________________________

__________________________________________________________________________
Do you have or have your ever been treated for:
High Blood Pressure ____Yes ___No
Liver Disease ____Yes____No
Heart Disease ____Yes ____No
Kidney Disease____Yes____No
Asthma ____Yes____No
Cancer ____Yes____No
Emphysema____Yes ____No
Other: (explain)______________

Have you ever had a problem with bleeding?____Yes ____No
Have you ever had a problem with anesthesia? ____Yes ____No

Do you smoke? ____Yes ____No If yes, how many packs per day?______________________

Do you drink alcohol?____Yes ____No If yes, how much/how often?_____________________

Signature of patient or responsible party: ____________________________
Date:_________