Anchor Medical Group

PATIENT MEDICAL HISTORY

FIRST NAME * LAST NAME * GENDER * DATE OF BIRTH * REASON FOR TODAYS VISIT *

MEDICATIONS

Medication 1 Dose (ie, Mg, Mcg) Directions Medication 2 Dose (ie, Mg, Mcg) Directions Medication 3 Dose (ie, Mg, Mcg) Directions Medication 4 Dose (ie, Mg, Mcg) Directions MEDICATION 5 Dose (ie, Mg, Mcg) Directions Medication 6 Dose (ie, Mg, Mcg) Directions Medication 7 Dose (ie, Mg, Mcg) Directions Medication 8 Dose (ie, Mg, Mcg) Directions Medication 9 Dose (ie, Mg, Mcg) Directions Medication 10 Dose (ie, Mg, Mcg) Directions Comments

ALLERGIES

Medication 1 Reaction Medication 2 Reaction Medication 3 Reaction

PAST MEDICAL HISTORY

Check all symptoms or conditions that apply. If no symptoms click none

Allergy/ Dermatology * Cardiovascular * Endocrine * Gastrointestinal * Hematologic * Musculoskeletal * Neurologic/ Genetic * Pulmonary * Renal/ Genitourinary * Mental Health * Infectious Disease * Other Medical Conditions Not Listed

SURGERIES AND HOSPITALIZTIONS

Please list surgeries and hospitalizations. Include the year and the surgeon who performed them if known.

SURGERY/HOSP Last Colonoscopy

MEDICAL CARE

List any other providers participating in your care:

WOMENS HEALTH

Number of Pregnancies: Number of Deliveries Type of Delivery Complications Last Menstral Period: Number of Miscarrages: Number of Abortions: Pre-Term Labor: Age Of Menopause: (If Applicable) Current Birth Control Method: If you are not using birth control would you like to discuss your options? Gyn Surgeries: Last Pap Smear: Any Abnormal Pap Results? If Yes, Describe Last Mammogram Any Abnormal Mammogram Results? If Yes, Describe Last Bone Density Scan Any Abnormal Results? If Yes, Describe

SOCIAL HISTORY

Tobacco use:

Do You Or Have You Used Cigarettes, Pipe, Cigar, Snuff Or Chew? Number of years: Do you use tobacco now? How many packs per day do you or did you smoke? Year quit: Do you use smokeless (chewing) tobacco now? How much smokeless tobacco per day do you or did you use? Number of years: Year quit:

ALCOHOL

Do you drink alcohol? If yes, what kind? How many days per week do you drink? How many drinks per day? What is the maximum number of alcoholic beverages you will drink in a 24 hour period?

DRUGS

Do you or have you used marijuana or recreational drugs (cocaine, amphetamines, heroin, etc.)? Current use: Prior use:

LIFESTYLE

Occupation: Employer: Marital status: Spouses name: Number of children: Ages of Children: Sexual Orientation: Religion or church: Hobbies:

EXERCISE

Do you exercise regularly? Type of exercise: How Long (minutes)? How often?

FAMILY MEDICAL HISTORY

FAMILY HISTORY

For each of the following family members please check ALL conditions that apply

Mother DETAILS and AGE OF ONSET Father DETAILS and AGE OF ONSET Maternal Grandmother DETAILS and AGE OF ONSET Maternal Grandfather DETAILS and AGE OF ONSET Paternal Grandmother DETAILS and AGE OF ONSET Paternal Grandfather DETAILS and AGE OF ONSET Sister(s) DETAILS and AGE OF ONSET Brother(s) DETAILS and AGE OF ONSET Daughter(s) DETAILS and AGE OF ONSET Son(s) DETAILS and AGE OF ONSET REFERRED BY NAME OF PERSON COMPLETING THIS FORM * RELATIONSHIP TO PATIENT *

BY TYPING BELOW, I CERTIFY THAT THIS REPRESENTS MY ELECTRONIC SIGNATURE AND I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE ALL THE INFORMATION I HAVE FURNISHED ON THIS FORM IS COMPLETE, TRUE AND ACCURATE

PATIENT OR GUARDIAN SIGNATURE * TODAYS DATE *