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NAME
*
First
Last
TODAY'S DATE
*
MM slash DD slash YYYY
EMAIL
*
DATE OF BIRTH
*
MM slash DD slash YYYY
REASON FOR VIST
*
DRUG ALERGIES
*
FAMILY HISTORY
PLEASE INDICATE IF POSITIVE HISTORY
DECEASED
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
HYPERTENSION
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
DIABETES
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
HEART DISEASE
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
STROKE
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
KIDNEY DISEASE
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
OBESITY
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
GLAUCOMA
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
LIVER DISEASE
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
DEPRESSION OR BIPOLAR DISEASE
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
COLON OR RECTAL CANCER
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
BREAST CANCER
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
OTHER CANCER
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
OTHER
SELF
FATHER
MOTHER
SISTERS
BROTHERS
DAUGHTERS
SONS
WHEN WAS YOUR LAST:
PNEUMONIA VACCINE
FLU VACCINE
TETANUS VACCINE
MAMMOGRAM
COLONOSCOPY
BONE DENSITY
DILATED EYE EXAM
PAP SMEAR
CHRONIC MEDICAL PROBLEMS:
INDICATE IF POSITIVE
ASTHMA
BLOOD CLOTS
BLOOD TRANSFUSION
CANCER
CHRONIC LUNG DISEASE
DEPRESSION
DIABETES
DIVERTICULOSIS
HEART DISEASE
HYPERTENSION
KIDNEY STONES
GOUT
PNEUMONIA
STROKE
THYROID PROBLEM
STOMACH ULCERS
NONE
Other
MEDICATION LIST
*
HOSPITAL ADMISSIONS
*
OTHER PHYSICIANS YOU SEE
*
SOCIAL HISTORY
WORK STATUS
*
OCUPATION
*
DO YOU DRINK ALCOHOL?
*
YES
NO
IF YES, HOW MANY OZ. PER WEEK
OZ. PER WEEK
DO YOU SMOKE?
*
YES
NO
FORMER SMOKER
YEAR QUIT
YEARS
IF YES,
CIG. PER DAY
FEMALE MENSTRUAL HISTORY
AGE OF ONSET
REGULAR
IRREGULAR
LAST MENSTRUAL PERIOD
MM slash DD slash YYYY
MENSTRUAL FLOW
HEAVY
MODERATE
LIGHT
AVERAGE LENGTH
CYCLE INTERVAL
BIRTH CONTROL
YES
NO
BIRTH CONTROL METHOD
MENOPAUSE
YES
NO
# OF PREGNANCIES
# OF LIVE BIRTHS
# OF MISCARRIAGES
# OF LIVING CHILDREN
BACKGROUND
LANGUAGES SPOKEN
*
ENGLISH
SPANISH
VIETNAMESE
Other
