Patient Intake: Medical History

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Name/Practice Name: ____________________________
Address: _____________________________________________
Address: _____________________________________________
City, State, ZIP: ________________________________________
Phone: _______________________________________________
Fax: _________________________________________________
PATIENT INTAKE: MEDICAL HISTORY
(To be completed by patient)
Use the opposite side of the page as necessary to complete your answers. Please print legibly.
Name: _____________________________________________________________________________________
Address: ____________________________________________________________________________________
Phone: (w) __________________________ (h) _________________________ (c) ________________________
DOB: _________________________ Age: ______________SS no.: ___________________________________
Emergency contact: ___________________________________________________________________________
Relationship to patient: ________________________________ Phone: _________________________________
Primary care physician: ________________________________ Phone: _________________________________
Date of last physical: _______________ Have you ever had an EKG? ( ) N ( ) Y Date: _________________
:
Current or past medical conditions (check all that apply)
( ) Asthma/respiratory
( ) Cardiovascular (heart attack, high cholesterol, angina)
( ) Hypertension
( ) Epilepsy or seizure disorder
( ) GI disease
( ) Head trauma
( ) HIV/AIDS
( ) Diabetes
( ) Liver problems
( ) Pancreatic problems
( ) Thyroid disease
( ) STDs
( ) Abnormal Pap smear
( ) Nutritional deficiency
:
Other (Please describe)
___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If there a family history of any of the illnesses listed above, please put an “F” next to that illness.
MD NOTES: __________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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