GENERAL MEDICAL INFORMATION
Patient Information
Patient Name
Date
Reason for Today’s Visit (main problem and duration):
Primary Care Physician
Address
Other Physicians Currently Treating You
Pharmacy
Address
Phone
Medications / Allergies
Current Medications and Supplements (plus
Dosage
)
Allergies to Medication
No
Yes
What drug name / dosage / reaction?
Allergies to Tape, Soaps or Solutions, Latex
No
Yes
Other Sensitivities
Describe
Social History
Marital Status
Single
Married
Widowed
Divorced
Separated
Number of Children
Do You Smoke?
No
Yes
No. of Packs/day
Smoking in Home?
No
Yes
Previous Smoker?
No
Yes
When Stopped?
Cats in Home?
No
Yes
Dogs in Home?
No
Yes
Caffeine Intake Daily (Coffee, Tea, Soft Drinks) - Cups per Day
Do You Regularly Drink Alcohol?
No
Yes
Amount per Day
Family History
Do You Have a Family History (Mother, Father, Siblings, Grandparents) with:
High Blood Pressure
No
Yes
Epilepsy/Seizures
No
Yes
Cancer
No
Yes
Alzheimer's/memory disorder
No
Yes
Heart Attack/Stroke
No
Yes
Diabetes
No
Yes
Allergies
No
Yes
Asthma
No
Yes
Eczema/Psoriasis
No
Yes
Hearing Loss
No
Yes
Other