Medical History - New Patient Questionnaire Page 3
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1
2
3Tobacco product:
How much:
Years:
12. Do you drink alcohol?
Yes
No
How many of each do you drink a day?
Beer:
Wine:
Liquor:
13. Do you take any recreational drugs?
Yes
No
14. Are you taking any prescription drugs currently?
Yes
No
List drugs, dosage, and how often you take them.
Drug Name:
Dosage:
How often:
Drug Name:
Dosage:
How often:
Drug Name:
Dosage:
How often:
15. (Your Additional Question Goes Here.)
Tip: Only 5 lines available, so summarize.
16. (Your Additional Question Goes Here.)
Tip: Only 5 lines available, so summarize.
IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page
now so you don't lose your information.
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Parent category: Life