Medical Information

 

Name___________________________          Date of Birth____________

 

Please list:

 

Primary Care Physician __________________________    phone __________________

 

Other Current Physicians____________________________________________________

 

 

 

 

 

Current Medical Issues: ______________________________________________________

 

 

 

 

Hospitalizations: _____________________________________________________________

 

 

 

 

 

Current Medications  (and side effects): _______________________________________ ______________________________________________________________________________

 

 

 

 

Allergies: ____________________________________________________________________

 

Do you currently smoke?          Have you in the past?    

 

Are there any current health issues that impact you in your family?  Please describe.

 

 

 

Are there any past health issues in your family that have had a serious impact on you?

 

 

Is there anything else that would be useful for me to know about your health history?