Chronic Disease Management Medical History Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Contact Number
Address
Chronic Disease Information
Chronic Diseases (e.g. diabetes, hypertension, asthma)
Date of First Diagnosis
Treating Physician
Current Medications
List all current medications
Allergies
Drug/Other Allergies
Relevant Medical History
Past Surgeries/Hospitalizations
Family History of Chronic Diseases
Lifestyle Information
Do you smoke?
Yes
No
Former Smoker
Do you drink alcohol?
Yes
No
Physical Activity (frequency/type)
Dietary Habits
Other Notes / Concerns
Any Other Relevant Information