Metro Direct Care Medical Patient Portal

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Patient Name Phone Number * Address * Today's Date Age Date of Birth Date of last physical exam? What is the reason for your visit?

Symptoms

Check symptoms you having currently below.

General

Muscle/Joint/Bone

Pain, weakness numbness in

Genito-urinary

Gastrointestinal

Cardovascular

Eye/Ear/Nose/Throat

Skin

Men Only

Symptoms you are having that have not been listed

Women Only

Date of last menstrual period Date of last pap smear Date of last mammogram

Are you pregnant?

Symptoms you are having that have not been listed

Conditions

Please check conditions you have or have had in the past.

Type? Type? Conditions not listed

Hospitalizations

Please list year, hospital and reason for hospitalization

Surgeries

Please list the year and type of surgery

Medications

Please list all medications you are currently taking. If you know the dosage and number of times you take a day, this would be helpful.

Allergies

Medications and/or substances

Family Health History

Father

Age Deceased? Significant Health Problems

Mother

Age Deceased? Significant Health Problems

Siblings

Sex Age Deceased? Significant Health Problems Sex Age Deceased? Significant Health Problems Sex Age Deceased? Significant Health Problems Sex Age Deceased? Significant Health Problems Please list any other siblings as above: sex, age, if deceased and significant health problems. Please list any grandparent with significant health problems

Health Habits

Exercise Dieting? Are you on a prescribed medical diet? Number of meals you eat in an average day? Salt intake Rank fat intake Caffeine Do you drink alcohol? If yes, what kind and number of drinks per week? Tobacco use What type? If cigarette smoker, please list how many packs per day, number of years smoked and year quit? Do you use or have you used recreational or street drugs? If yes, please list the name of drug and frequency of use? Are you still using drugs? If no, year stopped?