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Kidney Care & Transplant Services of New England

Patient Medical History Form

Male Female


Current Medications

No Yes

Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:


Personal History

Do you now or have you ever had:

Kidney disease
Kidney stones
Anemia
High blood pressure
Gout
High Cholesterol
Hypothyroidism
Hyperthyroidism
Diabetes
Angina
Congestive Heart Failure
Edema

Previous Heart Attack
History of Blood Clots
HIV/AIDS
Hepatitis B
Hepatitis C
Stroke
Epilepsy (seizures)
Peripheral Vascular Disease (Poor Circulation)
Cancer
Leukemia

Please check off any vaccinations you have received and add the year if known.

Immunizations

Hepatitis B
Pneumovax
Influenza
Shingles

Family History

If Living




If Deceased





Social History

Tobacco Use

Current Former Never

Type:

Cigarettes Cigars Pipes Chewing Tobacco Vape


Alcohol Use

Current Former Never

Occasional 1 - 2 Drinks per day 3 or more drinks per day

Recreational Drug Use

Current Former Never


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