Health History
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1
2John Carpenter, M.D. and Ernest Pugh, M.D.
889B Rio East Court, Charlottesville, VA 22901
Telephone (434) 978-7100 Fax (434) 978-4100
HEALTH HISTORY
Chart No
:
Name: ___________________________________Birth Date: ______________________Age:____________
Social Security Number:
Phone (Day):
Date:
Cell:
Do you have an advance medical directive? Circle one:
Yes
No
PAST MEDICAL HISTORY: Have you ever had any of the following illnesses?
Please circle and state year of onset
Alcoholism/Addiction
Colitis
Hepatitis
Pneumonia
Allergy/hayfever
Depression
High cholesterol
Prostate disease
Anemia
Diabetes
High blood pressure
Seizures
Angina/Heart Attack
Gallbladder disease
Hives/eczema
Thyroid disease
Arthritis
Glaucoma
Kidney disease
Tuberculosis
Asthma
Gout
Migraines
Ulcers
Blood transfusions
Heart problems
Osteoporosis
Urinary infections
Cancer of:
Pancreatitis
Other:
HOSPITALIZATIONS: Were you ever hospitalized for operations, illness, or injury?
Reason/Year
Reason/Year
MEDICATIONS:
List current medications and dosage, including over the counter medications and supplements:
Medication
Dose
Frequency
Medication
Dose
Frequency
ALLERGIES: Allergy to any drug_____________________________________________________________
X-Ray Dye_____________________________ Food _____________________________________
IMMUNIZATIONS : (date of last)
Tetanus
Pneumonia
Influenza
Chickenpox
Hepatitis A
Hepatitis B
.
healthhistory1/7/2009
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