DATE__________________
PATIENT NAME__________________________________BIRTHDAY________________AGE___________
MARITAL
STATUS________________EDUCATION________________OCCUPATION_______________
1. CURRENT PROBLEM/CONCERNS_________________________________________________________
___________________________________________________________________________________________
2.
OPERATIONS-WHEN/WHERE_____________________________________________________________
___________________________________________________________________________________________
3.
HOSPITALIZATIONS-WHEN/WHERE______________________________________________________
___________________________________________________________________________________________
4. LIST
MAJOR MEDICAL / EMOTIONAL ILLNESSES YOU HAVE HAD.
DIABETES_______HIGH
BLOOD PRESSURE______CANCER________SEIZURES_________
HEPATITIS______LIVER______STOMACH______LUNGS______HEART______KIDNEY____
OTHER_____________________________________________________________________________
5. CURRENT
MEDICATIONS: (NAME, DOSE, HOW OFTEN TAKEN)
___________________________________________________________________________________________
___________________________________________________________________________________________
6. DRUG ALLERGIES:_______________________________________________________________________
7. FAMILY HISTORY:
MOTHER _____________AGE
________HEALTH __________CAUSE OF DEATH ___________
FATHER
_____________ AGE _______ _HEALTH _________CAUSE OF DEATH ____________
LIST ANY DISEASES WHICH BLOOD RELATIVES
HAVE:
DIABETES ________HIGH
BLOOD PRESSURE _______CANCER _______SEIZERES ________
HEPATITIS
_______LIVER _______STOMACH ________LUNG ________THYROID _________
8. DO YOU USE OR HAVE YOU EVER USED:
ALCOHOL_______________
TABACCO_____________________DRUGS____________________
9. LIST ANY ADDITIONAL INFORMATION YOU
FELL IS NECESSARY_________________________
___________________________________________________________________________________________
WOMEN ONLY
DATE OF LAST PERIOD __________________________
LIVE BIRTHS ____________________________
MISCARRIAGES __________LAST MAMMOGRAM ______________LAST
PAP SMEAR ____________