Medical History & Physical Click here to download our Medical History & Physical PDF or fill out the online form below. "*" indicates required fields Patient Name* First Last Date of Birth* MM slash DD slash YYYY Today's Date* 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?* Yes No Hobbies/Interests*Date of your last complete medical exam MM slash DD slash YYYY Health of FamilyPlease select the health of your family members below.Father (natural, biological) Good Poor Died If your Father is deceased, note age & cause of death. Include fatal accidents and suicides. Mother (natural, biological) Good Poor Died If your Mother is deceased, note age & cause of death. Include fatal accidents and suicides. Mother (natural, biological) Good Poor Died If your Mother is deceased, note age & cause of death. Include fatal accidents and suicides. Brother 1 Good Poor Died If your Brother is deceased, note age & cause of death. Include fatal accidents and suicides. Brother 2 Good Poor Died If your Brother is deceased, note age & cause of death. Include fatal accidents and suicides. Brother 3 Good Poor Died If your Brother is deceased, note age & cause of death. Include fatal accidents and suicides. Sister 1 Good Poor Died If your Sister is deceased, note age & cause of death. Include fatal accidents and suicides. Sister 2 Good Poor Died If your Sister is deceased, note age & cause of death. Include fatal accidents and suicides. Sister 3 Good Poor Died If 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)Spouse Good Poor Died If your Spouse is deceased, note age & cause of death. Include fatal accidents and suicides. Child 1 Good Poor Died If your Child is deceased, note age & cause of death. Include fatal accidents and suicides. Child 2 Good Poor Died If your Child is deceased, note age & cause of death. Include fatal accidents and suicides. Child 3 Good Poor Died If your Child is deceased, note age & cause of death. Include fatal accidents and suicides. Child 4 Good Poor Died If 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. FLU TETANUS RUBELLA PNEUMONIA TB SKIN TEST Select AllPlease specify the Year you received the selected ImmunizationsSocial HistoryDo you presently smoke?* Yes No If 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?* Yes No If yes, what Area(s) have you traveled too? Do you have pets?* Yes No If yes, what kind of pets do you have? Have you ever had birds?* Yes No IllnessesCheck 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?* Yes No If yes, please list the medications you are allergic to.Do you have other allergies?* Yes No If Yes, please indicate the type of allergiesHave you ever had skin testing?* Yes No What year did you have the testing preformed? Do you use home oxygen?* Yes No Any Comments or QuestionsTo submit, what is 75+2=* NameThis field is for validation purposes and should be left unchanged.
