Patient Full Name:
Date of Birth:
(ex. 01/01/2005)
/ /   
Sex:
 M F
Home Phone No.:
 (Area Code: 281 Number: 1234567)
Cell Phone No.:
(Area Code: 281 Number: 1234567)
Street Address
City:
State
Zip:
Email Address:
Marital Status:
 S M W D
Employment:
 FT PT RET N/A
Patient's Employer:
Patient's Work Phone:
 Area Code: 281 Number: 1234567)
How did you find us?
Family Physician:
Phone No.:
 (Area Code: 281 Number: 1234567)
Emergency Contact:
Relationship:
Home Phone Number:
 (Area Code: 281 Number: 1234567)
Cell Phone Number:
 Area Code: 281 Number: 1234567)
 
MEDICAL HISTORY
Patient Past Medical History - Have you ever had any of the following conditions? If yes, please list year you were diagnosed:
Asthma:
 Yes: No: Year:
Hay Fever:
Yes: No: Year:
Emphysema:
 Yes: No: Year:
Rheumatic Fever:
 Yes: No: Year:
Thyroid Disease:
 Yes: No: Year:
Thyroid Disease Type:
Cancer:
Yes: No: Year:
Cancer Type:
Heartburn/Reflux:
 Yes: No: Year:
Hives/Rash:
 Yes: No: Year:
Eczema:
 Yes: No: Year:
Sinusitis:
 Yes: No: Year:
Migraines:
 Yes: No: Year:
Diabetes:
 Yes: No: Year:
Heart Trouble:
Yes: No: Year:
High Blood Pressure:
 Yes: No: Year:
Stroke:
 Yes: No: Year:
Ulcer:
Yes: No: Year:
  Ulcer Type:
GERD:
Yes: No: Year:
Eye Redness or itching:
 Yes: No: Year:
Corrective glasses or contacts:
 Yes: No: Year:
Glaucoma or other vision problems:
 Yes: No: Year:
Hearing loss or ringing:
 Yes: No: Yea:r
Earaches, infections or drainage:
 Yes: No: Year:
Nose bleeds:
 Yes: No: Year:
Jaundice:
 Yes: No: Year:
Tuberculosis:
 Yes: No: Year:
Have you had any allergic reactions to drugs or medications?:
  Yes No Year:
If yes, to what?
Known food allergies:
 Yes: No: Year:
If yes, to what?
Environmental allergies:
 Yes: No: Year:
If yes, to what?
Tension Headaches:
 Yes: No: Year:
Fainting:
 Yes: No: Year:
Epilepsy:
 Yes: No: Year:
Arthritis:
 Yes: No: Year:
Hepatitis:
 Yes: No: Year:
Menstral Cramps:
 Yes: No: Year:
Veneral Disease:
 Yes: No: Year:
Blood Disorders:
 Yes: No: Year:
Anxiety:
 Yes: No: Year:
Depression:
 Yes: No: Year:
Psychiatric Treatment:
 Yes: No: Year:
If yes, for what:
Kidney Disease:
 Yes: No: Year:
HIV (exposure or diagnosis):
 Yes: No: Year:
Previous Hospitalizations/Surgeries/Serious Injuries? When?:
List of all current medications:
  
Use of Alcohol:
 Never: Rarely Occasionally Daily
Use of tobacco:

Do you smoke? Yes: No:
Have you ever smoked? Yes: No:
If yes, when did you quit:
How often did/do you smoke?
Daily Occasionally
Do you use other Tobacco Products: Yes: No:
If no, have you ever? Yes: No:
What Type? Pipe Cigars Chewing Tobacco
How often did/do you use it? Daily Occasionally

Sexually active:
 Yes: No:
STD:
 Yes: No:
**If female, please answer the following:  
Form of Birth Control:
 Oral Contraceptive: Yes: No:
  Condom: Yes: No:
  Spermicide: Yes: No:
  Other:
Hysterectomy:
 Yes: No:
Tubal Ligation:
 Yes: No:
Are you pregnant or breast feeding?:
 Yes: No:
Are you trying to get pregnant?:
 Yes: No:
Last Menstral Period:
 / /   
   

CERTIFICATION and VERIFICATION

I hereby certify that the above is accurate and true. I acknowledge that it is my responsibility to notify Suzanne Weakley, MD as soon as any changes occur in the above information.
Patient Signature Date

 

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