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Patient History
Name
Date of Birth
Sex
Male
Female
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Home Phone
Cell Phone
Pharmacy
Email Address
Marital Status
Single
Married
Divorced
Widowed
Ethnicity
Hispanic
Non-Hispanic
Race
Caucasion
Black
Hispanic
Asian
More than 1 race
Illegal Drugs?
Yes
No
Homosexual
Yes
No
Alcohol Use
Yes
No
If yes, how many drinks per week?
Tobacco Use
Cigarettes
Yes
No
If yes, How many packs per day?
Smokeless Tobacco
Yes
No
If yes, for how many years?
Former Smoker
Yes
No
If yes, number of years quit
List all current medical problems:
List all current medical problems
List all drug allergies (include x-ray dye, etc.)
List all current medications (including dose, and over the. counter medications, and vitamins/herbal supplements)
Family History (please check if a blood relative has had any of the following)
Heart attacks/ heart disease
Cancer
Mental Illness
Stroke
Allergies
Bleeding Problems
High Blood Pressure
Kidney Stones
Alcoholism
Diabetes
Tuberculosis
Asthma
Colon Polyps
AIDS/HIV
Other
Mother
Age
Select
Living?
Yes
No
Cause of Death
Illness
Father
Age
Select
Living?
Yes
No
Cause of Death
Illness
Brother(s)
Age
Select
Living?
Yes
No
Cause of Death
Illness
Sisters(s)
Age
Select
Living?
Yes
No
Cause of Death
Illness
Children
Age
Select
Living?
Yes
No
Cause of Death
Illness
List all past surgeries (list procedure with date)
Health Maintenance
Have you had any of the following tests in the past?
Mammogram (If female)
Yes
No
Date
Pap Smear (If female)
Yes
No
Date
Bone Density Testing
Yes
No
Date
PSA/Prostate Exam (If male)
Yes
No
Date
Colonoscopy
Yes
No
Date
Pneumonia Vaccine
Yes
No
Date
Treadmill Cardiac Screening
Yes
No
Date
Cholesterol Screening
Yes
No
Date
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Phone:
(912) 805- 2640
Fax:
(912) 805- 2641
Address:
310 Maple Dr. | Vidalia, GA 30474
Hours:
Monday- Friday 8-5
Saturday 9-12
