Form Yp-0878 Medical History Form Page 2
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2ALLERGIES OR REACTIONS TO MEDICINES / FOOD / OTHER AGENTS:
MEDICATION
REACTION OR SIDE EFFECT
DATE
FAMILY HISTORY:
CANCER
ADULT IMMUNIZATIONS:
Please note if you have had any of
Check all that apply
the following immunizations
(Note Year)
(Year)
Father
Gardasil
Y
N ________
Mother
Hepatitis B:
Y
N ________
Maternal Grandfather
Influenza (yearly): Y
N ________
Maternal Grandmother
Pertussis:
Y
N ________
Paternal Grandfather
Pneumonia:
Y
N ________
Paternal Grandmother
Shingles:
Y
N ________
Brothers
Tetanus:
Y
N ________
Sisters
WOMEN:
MEN:
Date of last menstrual period: _____________________
Do you have any of the following problems:
# of pregnancies: ________ # of children: __________
Waking up at night to urinate?
c Yes c No
Pap smears: c normal Date_____ c abnormal Date_____
Difficulty starting urine stream?
c Yes c No
Mammogram: c normal c abnormal
Sexual concerns (getting or keeping an erection)
c Yes c No
Do you take any of the following:
Have you had an abnormal PSA test?
c Yes c No
Calcium:
c Yes c No c Past
Vitamin D:
c Yes c No c Past
Comments:
Estrogen (Premarin):
c Yes c No c Past
Progesterone (Provera): c Yes c No c Past
PATIENT ID
Name ___________________________________________
HERITAGE
HEALTHCARE
MRN ____________________________________________
PATIENT HISTORY FORM
Date of Birth _____________________________________
Side 2
Date of Service ___________________________________
YP-0878 (9/29/11)
PMM # 293912
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Parent category: Medical