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Available Forms

Patient Medical History
First, Middle, Last, Suffix
If you referred yourself, please type "SELF"
If you do not have a Primary Care Provider, please type "NONE"
Please note approximate duration of your complaint
Adverse reactions to medications or other substances, leading to rash, hives, throat swelling, shortness of breath, etc. [NOT merely nausea or vomiting]. If your allergen is not listed, please inform the physician at the time of your visit.
Please enter in any medication allergy not listed above
Please list ALL prescription medications, including dose and frequency of use. Be sure to include all aspirin products or blood thinners. If you are not taking prescribed medications, please type "NONE".
Please list ALL non-prescription medications, vitamins and supplements, including doses and frequency of use. If you none, please type "NONE".
Have you recently taken any steroids (prednisone, Decadron, etc.)?
Please check the appropriate box(es) regarding these medications

Social History

If you have never used tobacco, skip the next 2 questions
Enter number of packs/day
Enter number of years passed since you last used tobacco
If you do not consume alcohol (including beer and wine), skip the next question
How many alcoholic beverages do you consume per day?
If you do not use recreational drugs, skip the next question

Family Medical History

Please check the appropriate boxes for diseases of immediate family members (blood relatives)

Personal Medical History

Please list ALL chronic medical conditions, and all illnesses requiring hospital care (with approximate dates of treatment) NOT ALREADY ADDRESSED IN THE PREVIOUS SECTION. If you have no significant past medical history, please type "NONE"
Please list ALL operations, including approximate dates of treatment. If you have no significant past surgical history, please type "NONE"

Obstetrical/Gynecologic History

For men please enter n/a
For men please enter n/a
For men please enter n/a
For men please enter n/a

Review of Systems

Preventative Care

All immunocompetent individuals aged 65 and older should receive a pneumococcal vaccine

Advance Directives

If you have a Living Will, please bring a copy to your office visit. To learn more, visit: http://aging.sc.gov/legal/Pages/LivingWillAndPowerOfAttorney.aspx
If you have a Health Care Power of Attorney, please bring a copy to your office visit. To learn more, visit: htttp://aging.sc.gov/legal/Pages/LivingWillAndPowerOfAttorney.aspx
My religious beliefs prohibit me from accepting blood or blood product transfusions, even in the event of a life-threatening emergency
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