Medical History & Physical Click here to download our Medical History & Physical PDF or fill out the online form below. Patient Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Today's Date* Date Format: MM slash DD slash YYYY Would you like to discuss anything with the doctor?Who is your primary doctor?*Reason for visit?Patient ProfileSelect Marital Status* Single Married Separated Divorced Widowed Last School Grade completed*Occupation*Occupation - are you retired?*YesNoHobbies/Interests*Date of your last complete medical exam Date Format: MM slash DD slash YYYY Health of FamilyPlease select the health of your family members below.Father (natural, biological)GoodPoorDiedIf your Father is deceased, note age & cause of death. Include fatal accidents and suicides.Mother (natural, biological)GoodPoorDiedIf your Mother is deceased, note age & cause of death. Include fatal accidents and suicides.Mother (natural, biological)GoodPoorDiedIf your Mother is deceased, note age & cause of death. Include fatal accidents and suicides.Brother 1GoodPoorDiedIf your Brother is deceased, note age & cause of death. Include fatal accidents and suicides.Brother 2GoodPoorDiedIf your Brother is deceased, note age & cause of death. Include fatal accidents and suicides.Brother 3GoodPoorDiedIf your Brother is deceased, note age & cause of death. Include fatal accidents and suicides.Sister 1GoodPoorDiedIf your Sister is deceased, note age & cause of death. Include fatal accidents and suicides.Sister 2GoodPoorDiedIf your Sister is deceased, note age & cause of death. Include fatal accidents and suicides.Sister 3GoodPoorDiedIf your Sister is deceased, note age & cause of death. Include fatal accidents and suicides.List any other Brother(s) or Sister(s) - please include their Health: Good, Poor or Died.(if deceased, note age & cause of death. Include fatal accidents and suicides)SpouseGoodPoorDiedIf your Spouse is deceased, note age & cause of death. Include fatal accidents and suicides.Child 1GoodPoorDiedIf your Child is deceased, note age & cause of death. Include fatal accidents and suicides.Child 2GoodPoorDiedIf your Child is deceased, note age & cause of death. Include fatal accidents and suicides.Child 3GoodPoorDiedIf your Child is deceased, note age & cause of death. Include fatal accidents and suicides.Child 4GoodPoorDiedIf your Child is deceased, note age & cause of death. Include fatal accidents and suicides.List any other Children - please include their Health: Good, Poor or Died.(if deceased, note age & cause of death. Include fatal accidents and suicides)Immunizations - Check those you have received. Select All FLU TETANUS RUBELLA PNEUMONIA TB SKIN TEST Please specify the Year you received the selected ImmunizationsSocial HistoryDo you presently smoke?*YesNoIf yes, how many years have you smoked?How much do you smoke per day?If you are an ex-smoker, how many years did you smoke?How much did you smoke per day?Have you traveled out of the area in the last year?*YesNoIf yes, what Area(s) have you traveled too?Do you have pets?*YesNoIf yes, what kind of pets do you have?Have you ever had birds?*YesNoIllnessesCheck all Illnesses you have had: Alcoholism Anemia Bleed Easy Blood Clots Cancer, Tumor Depression Diabetes Drug abuse Eczema, Hives, Rash Epilepsy, Seizures Eye Protection Glaucoma Heart Disease High Blood Pressure Excessive Snoring Liver Disease, Hepatitis or Yellow Jaundice Lung Disease Nervous Breakdown Thyroid Disease Ulcer in stomach or duodenum Check all Illnesses any Blood Relative has had: Alcoholism Anemia Bleed Easy Blood Clots Cancer, Tumor Depression Diabetes Drug abuse Eczema, Hives, Rash Epilepsy, Seizures Eye Protection Glaucoma Heart Disease High Blood Pressure Excessive Snoring Liver Disease, Hepatitis or Yellow Jaundice Lung Disease Nervous Breakdown Thyroid Disease Ulcer in stomach or duodenum Hospitalizations / SurgeriesList what the illness was, what kind of operation and the year it occurred. Exclude normal pregnancies.MedicationsList all medications, birth control pills vitamins and/or herbal/natural supplements you take with or without prescription. Include strength if known.Are you allergic to any medications?*YesNoIf yes, please list the medications you are allergic to.Do you have other allergies?*YesNoIf Yes, please indicate the type of allergiesHave you ever had skin testing?*YesNoWhat year did you have the testing preformed?Do you use home oxygen?*YesNoAny Comments or QuestionsCAPTCHA