MEDICAL HISTORY
Please fill out the form in detail, as this will improve our ability to provide you with quality healthcare. Everything we ask is important for health decisions, screening, or risk.
Past Medical History
List any and all medical problems you've had in the past, not listed above.
List number of pregnancies, deliveries, miscarriages/abortions, first date of last menstrual period. Any abnormal pap smears?
List prior surgeries AND dates.
List all your medications, the dose, and how many times you take per day
List any serious reactions to medications or any other allergies.
Family History
List age and major health problems, or age of death, for Father, Mother, Brothers, and Sisters.
Social History
List packs per day, how many years smoking, or quit date for ex-smokers.
Prevention
Individuals seeking treatment from our office are not considered active patients until the practice has completed an assessment of the individual at an office visit and thereafter notifies the individual of being accepted as a patient. Please understand that simply making an appointment or filling out paperwork is not adequate to establish a patient-physician relationship.
