PATIENT’S NAME:
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Reason for this appointment: |
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List any medications you are
taking now. |
Strength (milligrams) |
How often do you take this? |
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List any surgeries of
hospitalizations you have had |
Approximate date |
Physician’s name |
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List any allergies you have |
What type of reaction did
you have? |
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If you smoke, how many years
have you done so? |
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How many packs/day average
during that time? |
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If you have, at what age did
you quit? |
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If you drink alcohol, how
many drinks per week? |
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How many cans of soda do you
drink per day? |
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How many cups of caffeinated
coffee per day? |
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Females: Date
of last menstrual period? |
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Are your periods regular? |
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Number of pregnancies? |
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Number of births? |
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Any complications to you with delivery? |
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Problem |
Patient |
Family Member |
Please Explain |
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High Blood Pressure |
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Heart problems |
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Headaches |
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Respiratory or lung problems |
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Thyroid disease |
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Jaundice/Hepatitis |
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Bleeding tendencies |
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Bowel / GI problems |
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Kidney Problems |
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Anemia / Blood disorders |
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Diabetes |
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Cancer |
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Neurologic problems |
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Eye problems |
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Glaucoma |
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Please bring or have your physician
send any lab test results, urinalyses, urine cultures or pertinent X-rays to
our office. Thank you for your
assistance.