Patient's Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
SSN
*
Reason for Visit
*
Medications
*
Please list all prescriptions, over-the-counter medications, vitamins, and supplements. Type "none" if you are not currently taking any medications.
Current or Past Medical Problems
Please check all that apply.
Notes
Please add additional information about medical conditions if necessary.
Surgeries or Procedures
Please check all that apply.
Notes
Please add additional information and other surgeries or procedures if applicable.
Family Medical History
*
Please list any major illnesses (such as cancer, Diabetes, heart disease, etc.) for your mother, father, grandparents (on both sides of your family), siblings, and children. If there are no medical conditions in your family history, please type "none" below.
Colonoscopy
*
Doctor Name and Year Performed
Bone Density/DEXA
*
Doctor Name and Year Performed
Mammogram
*
Doctor Name and Year Performed
Pap Smear
*
Doctor Name and Year Performed
Digital Rectal Exam (Prostate Exam)
*
Doctor Name and Year Performed
MRI/CT/X-Ray
*
Type of Exam
*
Doctor Name and Year Performed
Flu Shot
*
Doctor Name and Year Performed
Pneumonia Shot (13/23)
*
Doctor Name and Year Performed
Tetanus Shot
*
Doctor Name and Year Performed
Who was your previous Primary Care Provider?
*
What specialists do you see?
*
Caffeine
*
chocolate, soda, tea, coffee
Quantity
*
If "Yes", please list type, amount of each, and how often.
Tobacco
*
cigarettes, smokeless tobacco, vape/e-cig
Quantity
*
Recreational/Street Drugs
*
marijuana, cocaine, prescriptions, stimulants, or other drugs
Quantity
*
Alcohol
*
beer, wine, liquor
Quantity
*
Are you concerned about how much you consume?
*
Exercise
*
Quantity
*
Please describe how often and what types of exercises.
Today's Date
*
MM
DD
YYYY
