Medical/Surgical History
Please list known diagnoses (e.g. hypertension, diabetes, etc.)
Please list type of surgery, date and provider if known (e.g. Appendectomy - 1998, Dr Lap)
Please list health care providers you see on a regular basis (e.g. Dr Bones - Orthopedics)
Personal Information
If retired, what type of work did you do before retiring?
Family Medical History
Please indicate date of birth and known diagnoses (e.g. born 1948, hypertension, diabetes, etc).
For heart attack, stroke or cancer, please estimate age at time of diagnosis (e.g. heart attack age 54, prostate cancer age 72).
Allergies/Medications
please indicate name of medication and reaction (e.g. amoxicillin - rash)
Please list all prescription medications you currently take (e.g. Lisinopril 10 mg daily)
Preventive Medicine
please indicate the performing physician and year completed. If none, type "none"
please, indicate facility and most recent year. If none, type "none"
please indicate the performing physician and year completed
please indicate the performing physician and year completed - PSA or digital rectal exam
Please list any adult immunizations you have had and the year (e.g. tetanus, 1998)
