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?