Name___________________________ Date of Birth____________
Primary Care Physician __________________________ phone __________________
Other Current Physicians____________________________________________________
Current Medical Issues: ______________________________________________________
Current Medications (and side effects): _______________________________________ ______________________________________________________________________________
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?