PATIENT FORM. PATIENT INFORMATION First Name Last Name MI Date of Birth. Address City State Zip

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PATIENT FORM PATIENT INFORMATION First Name Last Name MI Date of Birth Address City State Zip Home Phone Work Phone Cell Phone Contact Preference May we leave you a message regarding medical care & Home Phone Work Phone Cell Phone test results? Yes No Email Social Security No Gender Male Female Marital Status Married Single Divorced Widowed Race American Indian or Alaskan Native Asian Black/African American White Hawaiian/Pacific Islander More than one Ethnicity Hispanic/Latin Decent Not Hispanic/Latin Decent Primary Care Physician Referring Physician Reason for your visit today Other physicians involved in your care Pharmacy Name Pharmacy Address/Crossroads Pharmacy Phone Occupation Employer Emergency Contact Emergency Contact Phone RELEASE OF MEDICAL INFORMATION Name Phone Name Phone INSURANCE INFORMATION Primary Insurance Company Do not release my information to anyone Insurance Company Address Policy Holder Name Policy Holder Date of Birth Policy Holder Employer Identification Number Secondary Insurance Company Group/Policy Number Insurance Company Address Policy Holder Name Policy Holder Date of Birth Policy Holder Employer Identification Number Group/Policy Number

PAST MEDICAL HISTORY (Check all that apply; fill in dates where appropriate) Kidneys/Bladder/Prostate Frequent Urinary Tract Infections (>2-3/year) Episodes of Pyelonephritis (Kidney Infection) Kidney Stones Enlarged Prostate History of Acute Kidney Failure, Date: Blood in the Urine, Date: Protein in the Urine, Date: Incontinence Overactive Bladder Kidney Cysts/Polycystic Kidneys Head, Ears, Nose, Throat Hearing Loss Vision Loss Glaucoma Cataracts Macular Degeneration Excessive Dry Eyes Nose Bleeds Nasal Allergies/Congestion Headaches Head Trauma Cardiovascular Hypertension, Year of Diagnosis: Coronary Artery Disease Myocardial Infarction (Heart Attack), Date: Congestive Heart Failure Atrial Fibrillation Ventricular Arrhythmias Pacemaker/Defibrillator Placement Peripheral Vascular Disease (poor circulation to legs) Valve Disease: Aortic Mitral Tricuspid Pulmonary Edema (Swelling) Aneurysm Lungs Emphysema/Bronchitis/COPD Asthma Tuberculosis Pulmonary Hypertension Endocrine and Glandular Disorders Diabetes Mellitus, Type: I II Year of Diagnosis: Underactive Thyroid Overactive Thyroid High Cholesterol Obesity Gastrointestinal Stomach Ulcer Acid Reflux/Heartburn Diverticulosis/Diverticulitis GI Bleeding Liver Disease/Cirrhosis Hepatitis A B C /Jaundice Pancreatitis Colon Polyps Hemorrhoids Blood and Oncology Cancer/Tumor, Location: Date: Chemotherapy? Yes No, Radiation? Yes No Blood Clots Anemia Bleeding Disorder Thrombocytopenia Leukemia/Lymphoma Musculoskeletal Disorders Arthritis: Osteoarthritis Rheumatoid Lupus Gout Low Back Pain Osteoporosis Use of Non-Steroidal Anti-Inflammatories (NSAID) Skin Disorders Psoriasis Dry Skin Skin Ulcers Neurologic/Psychiatric Seizures Strokes TIA (Mini-Strokes) Migraines Tremor Neuropathy Vertigo Depression Anxiety or Panic Attacks Bipolar Disorder Excessive Alcohol Use/Alcoholism Illegal Drug Use

PAST SURGICAL HISTORY (Check all that apply and provide dates where possible) Cholecystectomy (Gall Bladder Removal) Appendectomy Tonsillectomy/Adenoidectomy Reduction of Fracture Hysterectomy Mastectomy Left Right Cataract Extraction Left Right Other (list type and date) Coronary Artery Bypass: Vessel 1 2 3 4 5 6 Leg Bypass Left Right Colectomy Partial Total Hernia Repair: Inguinal Left Right ; Incisional, Ventral ALLERGIES TO MEDICATIONS Name of Medication (ex: Codeine) Description of Reaction or Accompanying Symptoms MEDICATION LIST Please list all current prescription and over-the-counter (OTC) medications you are currently taking or attach a copy of your current list of medications. Include hormones, birth control pills, vitamins, supplements, calcium, and special dietary aides. Also include medications that have been discontinued in the last 3 months and the date is was discontinued. Medication Name Dosage Frequency Prescribing Doctor (e.g. Lisinopril) (e.g. 40 mg, 20 units) (e.g. 1 tablet twice a day) (e.g. Dr. Smith) FAMILY HISTORY

Relative Living Age or Age of Death Mother Y N Father Y N List Illnesses and/or cause of death SOCIAL HISTORY Current Occupation: Employer: Hours worked each week: Previous Occupation: Are you disabled? Yes No If so, date and why: Highest Level of Education Completed: Marital Status: Married Single Divorced Widowed Who do you live with? Do you drink alcohol? Yes No If yes, what do you drink? Beer Wine Liquor, How many drinks in average week? Have you quit drinking? Yes No If so, when did you quit? How many drinks in average week? Do you smoke? Yes No If yes, how many packs/day? Have you quit smoking? Yes No If yes, how many packs/day? Age started: Age quit: Do you or did you ever smoke cigars, pipes, or chew tobacco? Yes No Do you or did you ever use street drugs (Cocaine, Marijuana, LSD, Speed, IV Drugs, etc.)? Yes No Do you drink coffee or caffeinated sodas frequently (< 2 per day)? Yes No If yes, how much each day? Have you had a blood transfusion within the last 15 years? Yes No HEALTH MAINTENANCE Colonoscopy, Date: Flu Vaccine, Date: Mammogram, Date: Pneumonia Vaccine, Date:

REVIEW OF SYMPTOMS (check all that apply, clarify below if needed) General Fever Chills Fatigue Weight gain/loss (> 10 lbs.) Recent Hospitalization Recent Illness Poor Appetite Skin Rashes Excessive Itching Ulcers on Skin Skin Color Changes Excessive Sweating Head, Eyes, Ears, Nose, Throat Headaches Blurred Vision Sudden Change in Vision Excessively Dry Eyes Frequent Bloody Nose Recurrent Nasal Congestion Ulcers in mouth/lips Dry Mouth Neck Neck Mass Neck Swelling Swollen Glands Lungs Shortness of Breath Wheezing Chronic Cough Bloody Sputum Heart Chest Pain Swelling of Feet Irregular Heart Beat Cramps in Legs with Walking Heart Murmurs Fainting or Passing Out High Blood Pressure Excessively Low Blood Pressure Heart Stent Pacemaker Wake up at Night Short of Breath Short of Breath Lying Flat in Bed Stomach/Intestines Abdominal Pain Blood in Stool Black Tarry Stools Nausea &/or Vomiting Diarrhea Frequent Heartburn Jaundice Polyps Kidneys/Bladder Blood in the Urine Urgency or Overactive Bladder Burning or Pain with Urination Urinate frequently (more than usual) Flank Pain Hesitancy or incomplete emptying Incontinence Excessive Urination at Night Foamy Urine Men Problems with Erections Weak or Slow Urinary System Women Lump or Mass in Breast Nipple Discharge Excessive Menstrual Bleeding o Muscles/Joints/Bones Frequent Gout Attacks Joint Pain Joint Stiffness Joint Swelling Muscle Pain Muscle Weakness Nerves/Brain Numbness or Tingling Dizziness or Vertigo Seizures Tremors or Shaking Memory Loss Balance Problems/Falls Psychiatric Depression Anxiety Insomnia/Trouble Sleeping Endocrine/Glands Thyroid Problems Cold Intolerance Heat Intolerance Excessive Thirst Blood/Lymph Nodes Anemia/Low Blood Count Easy Bruising Easy Bleeding Enlarged Lymph Nodes Explanation:

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