Patient Medical and Personal History


Please check conditions which you have had?

GENERAL





*If you checked serious infections insert the kind of infection you had.

CVS











HEENT




MUSCULOSKELETAL / EXTREMITIES






LYMPHATIC / HEMATOLOGIC





GI / GU

















SKIN / BREAST

NEUROLOGIC / PSYCHIATRIC







Please indicate any surgeries you have had by placing the year you had them in the boxes below:

Angioplasty

Carotid Artery Surgery

Other Vascular Surgery

Coronary Bypass Surgery

Chest / Lung Surgery

Tonsillectomy

Neuosurgey

Trauma Related Surgery

Back or Neck Surgery

Hip Surgery

Knee Surgery

Carpal Tunnel Surgery

Sinus Surgery

Ear Surgery

Stomach Surgery

Inguinal Hernia

Colonoscopy

Gallbladder

Appendectomy

Prostate Surgery

Bladder Surgery

Tubal Ligation

C-Section

Hysterectomy

Ovary Removed

Breast Surgery

Thyroid Surgery

Other

Other Surgery Name

Please indicate the year when you last had any of the following preventative tests or services.

Cardiac Angiogram

Stress Test

Echocardiogram

Chest X-ray

EKG

Flu Vaccine

Pneumonia Vaccine

Tetanus Vaccine

Hepatitis Vaccine

Bone Density Test

Prostate Cancer Blood Test

Rectal Exam

Colon Cancer Stool Test

Flexible Sigmoidoscopy

Barium Enema

Mammogram / Breast Exam

Pap Smear

Date of Last Physical Exam

Other

Other (Please Mention Test Name)

Please list any allergies or intolerance to drugs or other substances:

Please list the medications currently taken, their dosages, and how many times per day you take them:

FAMILY MEDICAL HISTORY

Please check or list any major illness in your family members. (Mother, Father, Brothers, Sisters or Children)









PERSONAL INFORMATION

Please check information that applies to you below:






































# of Drinks












# of Caffeine Drinks

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