This form helps your physician understand your medical concerns better. If you are uncomfortable with any question, do not answer it. If you cannot remember specific details, please provide your best estimate. Thank you!
Past Medical and Surgical History
If you have cancer(s), please indicate type in the space above.
If it applies, please indicate the year of last period.
If you have skin condition(s), please indicate type in the space above.
Surgeries
Please indicate any past surgeries you've had.
Current Prescription and OTC Medicines
For each drug, if possible, please describe the name of the drug, amount (in mg), # of tabs, and # of times per day.
Vitamins / Supplements / Herbs
Allergies to Medications
If you have any, please explain the types of reaction (e.g. hives, wheezing, upset stomach, swelling, etc.).
Immunizations
Please provide the date of your most recent immunizations:
Shot or illness
Health Maintenance Screening Tests
Family History
Indicate if you have family history of any of the following conditions:
If you have family history of cancer, please specify which family members (indicate if less than 60 at time of diagnosis).
Social history
Please indicate if you've never smoked, you've quit (include the date), or you are a current smoker. If you use other tobacco, please specify.
If you do not drink alcohol, leave empty.
Please leave empty if none needed.
Women's Health History
Symptoms
Please check the symptoms you have had in the past 2 months.
Ears/Nose/Throat/Mouth
