Patient Medical History (Page 5 of 5) in pdf

Patient Medical History Page 5

Life Style: Please check off answer and give detail if it applies:

Have you been a victim of abuse or domestic violence?  Yes  No

Do you feel safe at home?  Yes  No

Do you live alone?  Yes  No

Do you perform self -breast exam?  Yes  No

Do you drink milk or consume dairy products daily?  Yes  No

Do you take calcium tablets?  Yes  No

Do you exercise?  Yes  No If yes, frequency - how many times a week? _____________

Are you satisfied with your weight?  Yes  No

Please add any additional information:

__________________________________________________________________________________________________

AUTHORIZATION AND RELEASE:

I hereby certify that I have completed the above information to the best of my knowledge. I authorize, consent,

request, and agree to actively participate in such services as routine assessments, the performance of diagnostic

tests and procedures, care and treatment as self-referred or as ordered by my physician, his/her assistant or

designees.

_______________________________________________

________________________________

Signature

Date

Please mail or fax your completed form to our office prior to your appointment. If you cannot return your form

prior to your appointment, you must arrive 30 minutes early so we can enter your information into the computer.

Thank you for your attention and cooperation.

Revised 5/2013 HME

Patient Medical History Page 5