Horizon Medical Associates, LLC

PLEASE COMPLETE THIS FORM ONLY IF YOU ARE A NEW PATIENT. EXISTING PATIENTS DO NOT NEED TO COMPLETE THIS FORM.

Full Name * Date Of Birth * Please list any past or current medical issues. (e.g. diabetes, high blood pressure, asthma) If none, type NA * Please list your past surgical history. (e.g. appendix, gall bladder removal etc) If none, type NA * What medications are you currently taking? If none, type NA. * Any medication or food allergies? If yes, please list. If no, type NA. *

Please list your first degree family member medical conditions below:

Mother * Father * Sibling(s) * Do you smoke? * Do you drink alcohol? * Do you use any recreational drugs? * Have you ever tested positive for any sexually transmitted diseases (STDs)? * When was your last mammogram or other breast imaging study? (e.g. ultrasound) When was your last pap smear? * When was your last menstrual period? # of pregnancies (if applicable) When was your last colon cancer screening? If employed, what is your job? Will you take recommended vaccines? *