Patient Information Page 2
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ATIENT HISTORY
Name: __________________________________________________ Age: ______________ Date: _________________
R
eason for Visit:
List all other chronic medical problems:
List all medication dose and frequency:
1)
___________________________________
1) ___________________________________
2)
___________________________________
2) ___________________________________
3)
___________________________________
3) ___________________________________
4)
___________________________________
4) ___________________________________
5)
___________________________________
5) ___________________________________
List all prior surgeries (include date):
Allergies and drug sensitivities:
1)
___________________________________
1) ___________________________________
2)
___________________________________
2) ___________________________________
___________________________________
3) ___________________________________
3)
F
AMILY HISTORY
Has a blood relative had any of the following: (Circle answer & indicate relative, i.e. Mother, Sister, Maternal Aunt,
Father, Paternal Grandfather etc. If uncertain, leave blank)
Relationship
Relationship
Cancer (type)
no yes_________________
Asthma
no yes_________________
Tuberculosis
no yes_________________
Emphysema/COPD
no yes_________________
Diabetes
no yes_________________
Allergies
no yes_________________
Heart disease
no yes_________________
Drug/Alcohol Prob
no yes_________________
High Cholesterol
no yes_________________
Depression
no yes_________________
High blood Pressure
no yes_________________
Mental Illness
no yes_________________
Obesity
no yes_________________
Gout
no yes_________________
Migraine Headaches
no yes_________________
Thyroid Disease
no yes_________________
Stroke
no yes_________________
Ulcer
no yes_________________
Epilepsy/Seizure
no yes_________________
Kidney Disease
no yes_________________
Anemia
no yes_________________
Glaucoma
no yes_________________
Bleeding Tendency
no yes_________________
Other (specify)
no yes_________________
Blood Clots
no yes_________________
Other (specify)
no yes_________________
S
OCIAL HISTORY
?
H
?
N
H
?
Do You Smoke
no yes
ave you ever smoked
no yes
umber of years _____
ow much
_____
?
H
?
Do you drink alcohol
no yes
ow many drinks per day
?
H
?
Do you regularly drink caffeinated beverages, i.e. cola, coffee, tea
no yes
ow much per day
W
?
Do you use any illicit drugs? no yes
hat kind
M
S
?
Are you sexually active? no yes
arital Status M D S W
exual preference
Hetero / Homo / Bi
P
Current Occupation
rior Occupations
Females: Pregnancy History: Number of pregnancies _____ Number of deliveries____ Ages of children
N
Any complications with pregnancy or delivery? _________
umber of miscarriages:
abortions:
Immunizations: When was your last: Tetanus __________ Flu __________ Pneumonia ________
When was your last eye exam? _______________________________________
Patient Signature:
Date:
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