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 _____