Patient Medical Information

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Name *
Birthdate *
Age *
Gender (M / F) *
Pharmacy Name
Pharmancy Phone #

Medical Allergies: (List drug name and reaction)

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Past Surgical History (include biopsies, D&C's, tonsillectomy, etc.)

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Medical Problems (past and present: include serious injuries and any fractures)

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Current Medications With Dosage (including non-prescription drugs)

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OB-GYN History

Number of Pregnancies
Number Live Births
Number Stillborn or Miscarriages
Date Last GYN Exam
Name of Your Gynecologist
Have Your Gone Through Menopause (Yes / No)
If So At What Age
Date of Last Mammogram

Please List the Dates of Your Most Recent Immunizations

Tetanus
Flu
Pneumonia

Other

Date Of Last Chest Xray
Have You Had a DXA Scan: (Yes or No)
Is So When Was Your Last
When Was Your Last PPD (TB skin test)
Was It Positive or Negative

Family History: Please list the relationship to you of any "Blood Relatives" who have had any of the following diseases.

Diabetes
Arthritis
Rheumatoid Arthritis
Cancer
High Blood Pressure
Lupus
Heart Disease
Gout
Kidney Disease
Thyroid Disease
Psoriasis
Osteoporosis
Other

Social History

Martial Status
Number of Children
Hobbies or Interests
Last School Grade Completed
Describe Occupation
Sources of Unusual Stress
# Cigarettes Smoked / Day
# Alcoholic Drinks / Day
# Cups of Coffee / Day
Do You or Have You Ever Used Recreational Drugs
What Is Your Exercise Program
How Many Days Per Week Do You Exercise

Activities of Daily Living

List daily activities with which you have trouble because of your arthritis or muscle pain (e.g. combing hair, bathing, kitchen activities, yard work, etc.)
Can we leave a messge on your answering machine regarding medical information (Yes / No)

Please list the physicians who should get copies of your office visits

Physician Name
Address
City/State/Zip
Physician Name
Address
City/State/Zip

Please list any family members that can receive information on your care

Name
Relation
Name
Relation