Emergency Contact Form Page 2
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1
2JOSEPH J. FATA, M.D.
MEDICAL HISTORY
Last Name: ____________________________ First: ___________________________ Middle: ____________________
Information contained here will not be released except when you have authorized us to do so. Please answer all questions
to the best of your knowledge.
How were you referred to our office?
Friend or Family __________________ Doctor __________________________
Internet (Please identify any referrals from a specific website) ________________________________________________
Indianapolis Monthly Ad _______ Yellow Page Ad _______ Open House Invitation _______ Other _______________
What is the reason for your visit? _______________________________________________________________________
List Drug Allergies: _________________________________________________________________________________
Current medications with doses (including non-prescription drugs such as aspirin): ______________________________
__________________________________________________________________________________________________
Do you or have you ever had: (Circle and give date of onset)
Heart Disease
No
Yes
__________
Psychiatric illness
No
Yes
__________
Heart Attack
No
Yes
__________
Neurologic disease
No
Yes
__________
Lung disease
No
Yes
__________
Bleeding tendency
No
Yes
__________
Asthma
No
Yes
__________
Bruising tendency
No
Yes
__________
High blood pressure
No
Yes
__________
Radiation therapy
No
Yes
__________
Stroke
No
Yes
__________
Rheumatic fever
No
Yes
__________
Diabetes
No
Yes
__________
Ulcers
No
Yes
__________
Hepatitis
No
Yes
__________
Cancer
No
Yes
__________
Kidney disease
No
Yes
__________
Breast disease
No
Yes
__________
Thyroid disease
No
Yes
__________
Depression
No
Yes
__________
Tuberculosis
No
Yes
__________
Slow healing
No
Yes
__________
Do you smoke?
No ____
Yes ____
How much? ___________________________
Do you drink alcohol/beer?
No ____
Yes ____
How much? ___________________________
Are you at risk for HIV (AIDS)? No ____
Yes ____
Previous surgery (include dates): ______________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Family History of Illnesses: ___________________________________________________________________________
Do you know of a blood relative who has had a bleeding disorder or an adverse reaction to anesthesia?
No ____
Yes ____ (If yes, give details)_____________________________________________________
__________________________________________________________________________________________
EMERGENCYCONTACT: _____________________________________________________________________
Name
Relation
Daytime Phone #
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