Today's Date: |
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NAME:: * |
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ALLERGIES: |
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SMOKING HISTORY: |
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ALCOHOL HISTORY:: |
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CAFFEINE INTAKE:: |
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RECERATIONAL DRUGS:: |
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FAMILY HISTORY
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HAVE YOU OR ANY BLOOD RELATIVE HAD:
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ALCOHOLISM |
SELFRELATIVE |
ASTHMA |
SELFRELATIVE |
DEPRESSION
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SELFRELATIVE |
DIABETES |
SELFRELATIVE |
HEART DISEASE
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SELFRELATIVE |
LUNG DISEASE
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SELFRELATIVE |
STROKE
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SELFRELATIVE |
HYPERTENSION |
SELFRELATIVE |
EPILEPSY |
SELFRELATIVE |
TRAUMA |
SELFRELATIVE |
KIDNEY DISEASE
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SELFRELATIVE |
LIVER DISEASE
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SELFRELATIVE |
THYROID DISEASE |
SELFRELATIVE |
MENTAL ILLNESS
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SELFRELATIVE |
HEADACHES/MIGRAINE |
SELFRELATIVE |
HEADACHES/TENSION |
SELFRELATIVE |
BLEEDING DISORDER
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SELFRELATIVE |
CANCER |
SELFRELATIVE |
ALLERGY/HAYFEVER |
SELFRELATIVE |
SLEEP DISORDER
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SELFRELATIVE |
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SOCIAL HISTORY:
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MARRIEDDIVORCEDSINGLEWIDOWED VET:YESNO |
.:PLACE OF BIRTH:
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HOW MANY SIBLINGS?: |
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HOW MANY CHILDREN?: |
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EDUCATION: |
GRADE SCHOOLHIGH SCHOOLCOLLEGEPROFESSIONAL SCHOOL |
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SURGICAL HISTORY:
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SURGERIES: |
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MEDICATIONS CURRENTLY PRESCRIBED |
DRUG -- DOSE -- DURATION -- REASON FOR USE -- COMMENTS: |
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ADVERSE EFFECTS OF MEDICATIONS USED IN THE PAST:
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ADVERSE EFFECTS: |
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VITAMINS AND HERBAL SUPPLEMENTS USED:
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SUPPLEMENTS: |
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PREVIOUS MEDICATIONS AND REASONS STOPPED:
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PREVIOUS MEDS: |
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COMPLIANCE ASSESSMENT:
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HOW OFTEN DO YOU MISS A DOSE OF MEDICATION?: |
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ARE YOU HAVING ANY PROBLEMS WITH YOUR MEDICATION REGIMEN?: |
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ARE MEDICATION COSTS A PROBLEM?: |
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EMPLOYMENT: |
EMPLOYER:: |
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TYPE OF JOB:: |
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ADDITIONAL COMMENTS:: |
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