Medical History
Today's date:

Name:
Address:
Phone number:
Date of birth:
Social Security number:

DRUG ALLERGIES: (also describe the reaction you had)


Dates of recent VACCINATIONS:
	Flu shot:
	Pneumonia shot:
	Tetanus shot:
	Other:

Dates & results of RECENT SCREENINGS:
	Blood lipids:
	Blood sugar:
	Mammogram:
	Pap smear:
	P.A. test:
	Other:

INSURANCE company name:
	Group/policy number:
	Ins. co. phone number:

PHARMACY name & phone number:


NEXT OF KIN or person to notify in case of emergency:  (inlude phone number)


Other PHYSICIANS you are currently seeing and why you are seeing them:


The last time you saw a physician and why:



CURRENT MEDICATIONS (include name, dosage, and how many times a day you
take it)
	1.
	2.
	3.
	4.
	5.
	6.
	7.
	8.



Vitamins, minerals, herbs, alternative medications or treatments:

How much of the following do you consume daily?
	Tobacco:
	Alcohol:
	Coffee:

PRE-EXISTING CONDITIONS
(arthritis, blood pressure problems, diabetes, lung disease, cancer
of any kind, seizures, anything else)


RELEVANT FAMILY MEDICAL HISTORY: (include any family medical conditions
that put you at risk)


PREVIOUS SURGERIES: (dates, nature of surgery and related problems)

ADVANCE DIRECTIVE (Durable Power of Attorney) have office make copy

CURRENT HEALTH COMPLAINTS &/or QUESTIONS: (include any past treatment
for current problems and the results of the treatment)