PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

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Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand smoke exposure ALCOHOL ABUSE: (please circle) Daily Occasional Trying to Cut Down In Recovery Amount per week: DRUG USE: Past Use Current Marijuana Amphetamines Cocaine Designer/Club Route: Smoke Inject Ingest Topical How many times in the past year have you used recreational drugs or prescription medication for nonmedical reasons? One or More ADVANCE DIRECTIVE Do you have a living Will/DNR? YES NO Do you have a Durable Power of Attorney? YES NO If yes: Please Print Name Phone Number IMMUNIZATIONS: Please provide any known dates or full immunization record(s). Tetanus or Tetanus/Pertussis: Influenza: Shingles: Meningitis Hepatitis A: Hepatitis B: HPV: Pneumovax: Prevnar 13 : Other: ALLERGIES: Known Drug Allergies: YES No (Please add additional sheet if necessary) Other Allergies (latex, adhesive, food, environmental)

Name: DOB: FAMILY HISTORY What illness/conditions/diagnoses are in your family? If known, document the age of onset in the box for the appropriate disease and family member. Father Mother Sibling(s) Paternal Grandparent(s) Maternal Grandparent(s) Alcoholism/ Substance abuse Asthma Blood clots Breast cancer Colon cancer Prostate cancer Other cancer(s) Dementia Diabetes Heart disease High blood pressure High cholesterol Kidney disease Liver disease Lung disease Mental health/psychiatric Stroke Thyroid condition(s) Other

Patient Name: DOB: Please circle all that you ve experienced over the LAST TWO WEEKS General/ Constitutional Appetite change Excessive sweating Fatigue Fever Chills Insomnia Night sweats Weight gain Weight loss Eyes Blurred Vision Wear corrective lenses Double vision Dry eye Eye irritation Eye Pain Vision loss Spots in vision Ear, Nose & Throat Ear Pain Hearing loss Tinnitus/ringing Vertigo (dizziness, balance problems) Facial pain Bleeding gums Postnasal drainage Nose bleeds Nasal congestion Nasal drainage Sore throat Mouth sores Hoarseness Dental pain Cardiovascular Exertional dyspnea (trouble breathing) Nocturnal dyspnea (trouble breathing) Palpitations (irregular heartbeat) Decreased exercise tolerance Chest pain Exertional dyspnea Respiratory Cough Sputum production Coughing up blood Wheeze Pain with inspiration (deep breath Shortness of breath Snoring Gastrointestinal Abdominal pain Bloating Food intolerance Nausea Trouble swallowing Heartburn Change in bowel habits Constipation Diarrhea Vomiting Bloody stools Black stools Genitourinary Change in urine stream Dysuria (painful urination) Hematuria (blood in urine) Incontinence Nocturia (overnight urination) Urinary frequency Urinary retention Menstrual changes/concerns Urinary urgency Sexual dysfunction Vaginal discharge Musculoskeletal Back pain Joint instability Joint pain Joint swelling Limited range of motion Leg pain at night Leg pain with exertion Neck pain Stiffness Muscle cramps Muscle weakness Muscle aches Integumentary/ Skin Hair changes Lesions/changes in moles Breast masses Pigment changes Rash Pruritus/persistent itch Psoriasis Neurologic Abnormal gait/walking Focal weakness Headache(s) Confusion Memory problems Seizures Decreased sensation Balance problems Restless legs Other neurologic concern Speech problems Twitches/spasms Tremor Tingling Numbness Psychiatric Anxiety Decreased concentration Irritability Suicidal thoughts Thought of hurting others Panic attacks Insomnia Mood swings Sadness/tearfulness Depression Excessive sleep Hallucinations

Endocrine Cold intolerance Heat intolerance Excessive thirst Excessive hunger Excessive urination Hematologic/ Lymph Bruising tendency Bleeding tendency Swollen glands Recurrent infections Allergy/ Immunologic Eczema Immunocompromised Seasonal allergies Hives/Urticaria Any other symptoms: Patient Name: DOB: Your Care Team (other health care providers) Procedures (list year): Colonoscopy: Sigmoidoscopy: Stress Test: EKG: Mammogram: DEXA Scan: Please list any hospitalizations excluding surgeries/procedures Hospitalized for Year Surgical History Please list surgeries/procedures and add notes as needed other than listed above YEAR Surgery/Procedure Hospital/Location Complications/Additional Comments

MEDICATIONS: Please list any medications you are taking (including aspirin, vitamins and supplements), dosage, and how often you take. Current Medications Name of Medication Dose How often do you take Reason for taking medication PREFERRED PHARMACY Local: Mail Order:

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