GENERAL MEDICAL INFORMATION Name_______________________________________________ SS#_________________________________ Date___________________ Address______________________________________________City ________________________State_______ Zip__________________ Home Phone(______) ______-_________ Work Phone(______) ______-_________ Date of Birth________________________ Reason for your first visit:________________________________________________________________________________________ ____________________________________________________________________________________________________________ FAMILY HISTORY Father Mother Father's Parents Mother's Parents Siblings Children MEDICATIONS/SUPPLEMENTS Bleeding Disorder [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ Cancer [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ Diabetes [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ Glaucoma [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ Heart Disease [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ Hypertension [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ]   Kidney Disease [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] DRUG ALLERGIES Mental Illness [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ Osteoporosis [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ Seizures [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ Stroke [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ Thyroid Disease [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] [ __ ] ________________________________ HOSPITALIZATIONS & SURGERIES Reason Date Reason Date _________________________________________________________________________________________ _________________________________________________________________________________________ PERSONAL MEDICAL HISTORY Have you ever had any of the following? (Check all that apply & give dates) [ __ ] Allergies or Eczema [ __ ] Digestive Problems [ __ ] Memory Loss [ __ ] Arthritis [ __ ] Dizzy Spells [ __ ] Sexually TransmittedDisease [ __ ] Asthma [ __ ] Frequent Urinary Infections [ __ ] Shortness of Breath [ __ ] Blood in Stool [ __ ] Glaucoma [ __ ] Skin Disorder [ __ ] Cancer [ __ ] Hepatitis [ __ ] Stroke [ __ ] Cataracts [ __ ] Hemorroids [ __ ] TB/Lung Disorder [ __ ] Chest Pain/Pressure/Tightening [ __ ] Hypertension [ __ ] Ulcers [ __ ] Depression [ __ ] Heart Attack [ __ ] Other [ __ ] Diabetes [ __ ] Headaches __________________________ [ __ ] Difficulty Hearing [ __ ] Kidney Disease __________________________ Habits: Do you smoke? No[ __ ] Yes[ __ ] Cigarettes[ __ ] Pipe[ __ ] Cigars[ __ ] Number of years______ How much______ Do you drink alcohol? No[ __ ] Yes[ __ ] Number of Beers_____ Glasses of wine_____ Cocktails_____ per day   Exercise Routine _________________________________________________________________________________________ Women Only: Pregnant [ __ ] No [ __ ] Yes Planning pregnancy [ __ ] No [ __ ] Yes     Number of pregnancies_____ Abortions_____ Miscarriages _____