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Nurse Managed Health Center
540 S College Ave, Suite 130
Newark, DE 19713
Phone: 302-831-3195; Fax: 302-831-3193
Email: nm-hc@udel.edu
Name:
DOB:
Date:
Personal and Medical Information
 High Blood Pressure
 Asthma
 Diabetes
Check any of the medical conditions
 Heart Disease
 Emphysema
 Stroke
listed that you have been diagnosed
 High Cholesterol
 Cancer
 Blood Clots
with:
 Kidney Disease
 Anemia
List any other medical diagnosis you have:
 Yes  No
Have you been hospitalized for any significant injury or illness:
If yes list reason and dates:
F M
F M
F M
Check any of the medical conditions
  High Blood Pressure
  Asthma
  Diabetes
listed that either your Father or
  Heart Disease
  Emphysema
  Stroke
Mother have been diagnosed with:
  High Cholesterol
  Cancer
  Blood Clots
  Kidney Disease
  Anemia
If you are currently taking any prescription medicine, over-the-counter medicine, vitamins, herbs, nutritional
supplements or birth control pills, please list the medication name, dosage and frequency taken below
5.
1.
6.
2.
3.
7.
4.
8.
Are you ALLERGIC to
If yes what?
Type of reaction:
 Yes  No
any medication, food or
latex?
 Yes  No
Do you smoke?
If yes how much?
How many years?
 Yes  No
Did you ever smoke?
If yes, quit date?
# Yrs. smoked?
 Yes  No
Do you drink alcohol?
If yes how much?
How many years?
Do you drink
 Yes  No
Type:  Coffee  Tea  Soda
If yes how much?
caffeinated drinks
Do you normally eat a
 Yes  No
Meals per day?
Snacks per day?
balanced diet
Do you exercise on a
 Yes  No
Days per week #?
Type of:
regular basis?
 Husband
 Partner
 Single
Do you live with
 Yes  No
If yes who?
 Wife
 Children
 Roommate(s)
others?

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