Patient Medication/allergy And Visit Information

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*01*
Date: _______________
DOCTORS’ URGENT CARE
985 ROBERT BLVD, STE: 101
Account #: ____________
SLIDELL, LA 70458
PATIENT MEDICATION/ALLERGY AND VISIT INFORMATION
Name:
_______________________________________________
Cell Phone: _____________________
Why are you being seen today
________________________________________________________
?
Have you traveled outside of the United States in the last 6 months?
YES
NO
Is this a Motor Vehicle accident?
Are you allergic to latex?
YES
NO
YES
NO
Is this work related?
Are you possibly pregnant?
YES
NO
YES
NO
Date of Injury? ________________
VACCINES: Check one box for each vaccine:
Pneumonia
Influenza (Flu)
Tetanus
 Within past 5 years
 Within the past year
 Within the past 10 years
 No
 No
 No
 Unknown
 Unknown
 Unknown
ALLERGIES: Are you allergic to medications, iodine, food or tape?
Allergy
Reaction
Allergy
Reaction
MEDICATIONS: Please list all prescription medication, over the counter medication, vitamin and nutritional
supplements that you currently use.
Taken
Route
Name of
Dose
Directions
Purpose?
Today?
(Oral, Drops, Inhalation,
Medicine
(Such as 50 mg)
(How do you take it? Ex: 1 in a.m.)
Why do you take it?
Check Box
Injection, Skin or Spray)
if yes.


PATIENT (OR RESPONSIBLE PARTY) SIGNATURE:
_______________________________
RELATIONSHIP TO PATIENT: _____________________

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