CARY ADULT MEDICINE

Todays Date * First Middle Last Name * Date of Birth * Allergies to Any Medications * Please list other medications you may have an allergy to that are not included abovedication other than listed please list below Have you had an allergic reaction to any of the following * Please list all prescription medications with dose and # of times taken daily Have you ever had any of the following? Have you had any of these shots? Surgical History Have you had any of the following? * Has any one in your family had any of the following? Please list individual in your family had any of the above diseases and which disease they had Smoking History * If a smoker how many years did you smoke and how many on average packs per day? Alcohol Use * Recreational Drug Use * Caffeine Use * How many times a week do you exercise What type and for how long do you exercise? For Females Type of Birth Control Last Colonoscopy Next Colonoscopy Due For Females Last Mammogram For Females Last Bone Density Test For Females Last Pap Smear For Males Last PSA Prostate Blood test Last Physical Exam Last blood test for cholesterol Please list any religious or cultural needs ? Is there any additional history you would like to provide today?